ArticleLiterature Review

Mental health and gender dysphoria: A review of the literature

January 2016
International Review of Psychiatry 28(1):44-57

DOI:10.3109/09540261.2015.1115753

Authors:

Cecilia Dhejne

Karolinska Institutet

Roy van Vlerken

Vrije Universiteit Amsterdam

Gunter Heylens

Ghent University

Jon Arcelus

University of Nottingham

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Considérations épidémiologiques sur l’incongruence de genre chez les adultes, les adolescents et les enfants et les questions de santé mentale : une revue de la littérature

Article

Full-text available

Feb 2021
Sexologies

Résumé La recherche épidémiologique peut fournir une clef d’interprétation de l’incongruence de genre (IG) (Gender Incongruence [GI]) et d’identification des besoins médicaux des sujets avec une incongruence de genre. L’IG faisant l’objet de différentes définitions, il est difficile d’estimer sa véritable prévalence. Les données sur la prévalence de l’IG sont influencées par la définition nosographique et par les différentes méthodologies mises en œuvre par les chercheurs pour évaluer les nombres de cas. Selon les estimations existantes, la prévalence, qui présente de larges variations, se situe entre 0,1 % et 1,1 % chez les adultes, avec un ratio homme vers femme (ratio male-to-female [MtF]), femme vers homme (female-to-male [FtM]) de 1-6. Chez les enfants, la littérature rapporte une prévalence entre 1 % et 4,7 %, avec une prédominance du ratio MtF chez les enfants, et de 1,2 % à 16,1 % chez les adolescents pour lesquels le ratio FtM semble prédominant. Les études basées sur l’accès aux cliniques transgenres sont susceptibles de sous-estimer la prévalence de l’IG alors que les études qui mettent l’accent sur les données auto-déclarées ou déclarées par les parents pourraient surestimer le phénomène. La littérature décrit des taux élevés de troubles affectifs et d’anxiété (18–80 %), de fréquents troubles de la personnalité (20–70 %), des tentatives de suicide et des blessures auto-infligées chez les personnes vivant avec une incongruence de genre. Ces problèmes semblent s’améliorer après un traitement d’affirmation de genre. Certains auteurs font état d’une forte prévalence de troubles du spectre autistique (TSA) (Autistic Spectrum Disorders [ASD]) (6–14 %) chez les jeunes avec une incongruence de genre. Les taux de mortalité, les infections VIH et les maladies sexuellement transmissibles sont élevés chez les transgenres, probablement en raison d’un manque de prévention. Il est essentiel de déterminer la véritable prévalence de l’IG afin d’assurer un soutien médical adéquat. Les futures études devraient être basées soit sur de grandes cohortes multicentriques soit sur la population générale, faisant appel à des échantillonnages fondés sur les répondants et comprenant également des sujets qui n’ont pas recours aux services proposés par les cliniques transgenres, afin de minimiser les biais de sélection.

Epidemiologic considerations on gender incongruence in adults, adolescents and children and mental health issues: A review of the literature

Article

Full-text available

Jan 2021
Sexologies

Epidemiological research may offer a key to interpreting gender incongruence (GI) and identifying the medical needs of people with GI. Currently, it is difficult to estimate the real prevalence of GI due to the use of different definitions. The data on GI prevalence are influenced by case definition and by the different methodologies applied by researchers to assess cases. Estimations of prevalence therefore vary widely and are estimated between 0.1% and 1.1% among adults, with a male-to-female (MtF) – female-to-male (FtM) sex ratio of 1–6. For children, the literature reports a prevalence ranging from 1% to 4.7%, with a predominance of MtF for children and from 1.2% to 16.1% in adolescents, among whom FtM appears to be predominant. Studies based on access to gender clinics may underestimate GI prevalence while studies focused on self- or parent-reported data may overestimate the phenomenon. The literature describes high rates of affective and anxiety disorders (18–80%) and frequent personality disorders (20–70%), suicide attempts, suicide and self-harm among people with GI. These problems seem to improve after gender affirmation treatment. Some authors report a high prevalence of Autistic Spectrum Disorders (ASD) (6–14%) among youth with GI. Mortality rates, HIV infection and sexually transmitted diseases are high among the transgender population, probably related to lack of prevention. It is crucial to determine the true prevalence of GI in order to deliver adequate medical support. Future studies should be based on large multicenter cohorts or population-based surveys, and should adopt respondent-driven sampling while including individuals who do not seek services offered at gender clinics, to limit the selection bias.

Country-level structural stigma, identity concealment, and day-to-day discrimination as determinants of transgender people’s life satisfaction

Article

Full-text available

Feb 2021
Soc Psychiatr Psychiatr Epidemiol

Purpose Discriminatory laws, policies, and population attitudes, surrounding transgender people vary greatly across countries, from equal protection under the law and full acceptance to lack of legal recognition and open bias. The consequences of this substantial between-country variation on transgender people’s health and well-being is poorly understood. We therefore examined the association between structural stigma and transgender people’s life satisfaction across 28 countries. Methods Data from transgender participants ( n = 6771) in the 2012 EU-LGBT-survey regarding identity concealment, day-to-day discrimination, and life satisfaction were assessed. Structural stigma was measured using publicly available data regarding each country’s discriminatory laws, policies, and population attitudes towards transgender people. Results Multilevel models showed that country-level structural stigma was associated with lower life satisfaction, an association largely explained by higher levels of identity concealment in higher-structural-stigma countries. Yet identity concealment was also associated with lower day-to-day discrimination and therefore protected against even lower life satisfaction. Conclusion The results emphasize the importance of changing discriminatory legislation and negative population attitudes to improve transgender people’s life satisfaction, and also highlight targets for intervention at interpersonal and individual levels.

Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study

Article

Full-text available

Feb 2021
J SEX MED

Background In people diagnosed with Gender Dysphoria (GD), low perceived social support from their families and society has been suggested to be associated with poor quality of life and mental well-being. Aim To compare the perceived social support in individuals with GD with that in individuals without GD matched for age and gender. Methods The study group (n = 50) consisted of individuals diagnosed with GD via psychiatric evaluation. A control group (n = 50) was created by matching volunteers without GD by age and gender. Sociodemographic data form, Structured Clinical Interview Form for DSM-IV TR Axis I Disorders (SCID-I), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to gather data from participants. Outcomes comparing the perceived social support, the total and subscale MSPSS scores of groups were calculated. Results The presence of at least 1 psychiatric disorder was significantly higher in the GD group than in the control group, either lifetime or during evaluation (P < .001 and P = .025, respectively). The total MSPSS and family support subscale scores were found to be significantly lower in the GD group than in the control group (P = .001 and P ≤ .001, respectively). When the groups formed on the basis of gender identity (32 trans men vs 32 cis men and 18 trans women vs 18 cis women) were compared, only the family support subscale score was found to be lower in trans men than cis men (P = .005). In addition, comparisons within the groups formed based on sex assigned-at-birth revealed lower total, friend, and family support in those assigned female-at-birth and lower total and family support in those assigned male-at-birth in the GD group. A multiple linear regression analysis revealed that the presence of GD was significantly associated with total and family support MSPSS subscale scores. Clinical Implications The findings show that perceived social support in people diagnosed with GD is lower, even when the presence of psychiatric disorders is included in the analysis. Strengths and Limitations The matched case-control design was the major study strength, whereas the sample size was the major limitation. Conclusion Clinical care of people diagnosed with GD should include the evaluation of diverse sources of social support, efforts to strengthen family and friend support, maintenance of interpersonal relationships, and support of mental well-being. Kaptan S, Cesur E, Başar K, et al. Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study. J Sex Med 2021;XX:XXX–XXX.

Association Between Gender-Affirming Surgeries and Mental Health Outcomes

Article

Apr 2021

IMPORTANCE Requests for gender-affirming surgeries are rapidly increasing among transgender and gender diverse (TGD) people. However, there is limited evidence regarding the mental health benefits of these surgeries. OBJECTIVE To evaluate associations between gender-affirming surgeries and mental health outcomes, including psychological distress, substance use, and suicide risk. DESIGN, SETTING, AND PARTICIPANTS In this study,we performed a secondary analysis of data from the 2015 US Transgender Survey, the largest existing data set containing comprehensive information on the surgical and mental health experiences of TGD people. The survey was conducted across 50 states,Washington, DC, US territories, and US military bases abroad. A total of 27 715 TGD adults took the US Transgender Survey, which was disseminated by community-based outreach from August 19, 2015, to September 21, 2015. Data were analyzed between November 1, 2020, and January 3, 2021. EXPOSURES The exposure group included respondents who endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses. The comparison group included respondents who endorsed a desire for 1 or more types of gender-affirming surgery but denied undergoing any gender-affirming surgeries. MAIN OUTCOMES AND MEASURES Endorsement of past-month severe psychological distress (score of�13 on Kessler Psychological Distress Scale), past-month binge alcohol use, past-year tobacco smoking, and past-year suicidal ideation or suicide attempt. RESULTS Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these. Of the respondents in this study sample, 16 182 (81.1%) were between the ages of 18 and 44 years, 16 386 (82.1%) identified as White, 7751 (38.8%) identified as transgender women, 6489 (32.5%) identified as transgender men, and 5300 (26.6%) identified as nonbinary. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (adjusted odds ratio [aOR], 0.58; 95%CI, 0.50-0.67; P < .001), past-year smoking (aOR, 0.65; 95%CI, 0.57-0.75; P < .001), and past-year suicidal ideation (aOR, 0.56; 95%CI, 0.50-0.64; P < .001). CONCLUSIONS AND RELEVANCE This study demonstrates an association between gender-affirming surgery and improved mental health outcomes. These results contribute new evidence to support the provision of gender-affirming surgical care for TGD people.

Descriptive Study of Transgender Youth Receiving Health Care in the Gender Identity Program in Southern Brazil

Article

Full-text available

Mar 2021

Since 2014, the Gender Identity Program (PROTIG) of Hospital de Clínicas de Porto Alegre (HCPA) has been assisting transgender youth seeking gender-affirmative treatment offered at a public health-care service specializing in gender in southern Brazil. This article aims to analyze sociodemographic and clinical data regarding the diagnoses of gender dysphoria and gender incongruence, psychiatric comorbidities, and clinical aspects of a sample of transgender youths seeking health care in the gender identity program. The research protocol consisted of a survey of the data collected in the global psychological evaluation performed at the health-care service for youths diagnosed with gender incongruence and their caretakers. Participating in this research were 24 transgender youths between 8 and 16 years old with diagnostic overlap of gender dysphoria [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)] and gender incongruence [International Classification of Diseases, 11th Revision (ICD-11)] and 34 of their caregivers. Of the young people, 45.8% were positive for some psychiatric comorbidity throughout their lives, with almost half (45.4%) having two or more psychiatric comorbidities in addition to gender dysphoria. The mental health professionals comprising affirmation care teams face the challenge of adapting the care protocols to the uniqueness of each demand by developing individualized forms to promote healthy development. This can be done by focusing not only on medical and physical interventions for gender affirmation but also on the promotion of mental health and general emotional well-being. Thus, the gender affirmation model, which advocates for global assessment and personalized guidance, proved to be adequate. Nevertheless, access to multidisciplinary health services specializing in gender is essential for promoting the general well-being of the population of transgender youth.

Psychiatric Disorders in Female Psychosexual Disorders—A Nationwide, Cohort Study in Taiwan

Preprint

Full-text available

Jul 2020

We aimed to investigate whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2,240 enrolled individuals, with 560 patients with psychosexual disorders and 1,680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000-2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the non-cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI= 7.298 — 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in patients with psychosexual disorders.

The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review

Article

Full-text available

Jan 2021
Int J Environ Res Publ Health

This scoping review of UK evidence aimed to describe what is known about Lesbian, Gay, Bisexual, and Trans (LGBT+) health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. Using a scoping review methodology, we identified studies from database searches, citation tracking, and expert consultation. The in/exclusion criteria was based on the PICOS framework. The data were charted and then summarised to map the theoretical approaches and the main types of evidence and identify knowledge gaps. In total, 279 articles were screened and 83 were included in the final review. We found that there is limited UK research examining LGBT+ health inequality in cancer, mental health and palliative care. We would argue that this thin evidence base is partly due to national policy discussions of LGBT+ health inequality that are framed within a depoliticised ‘it’s getting better’ narrative, and an unwillingness to adequately acknowledge the unjust social and economic relations that produce LGBT+ health inequality. In addition, LGBT+ health inequality is depoliticised by existing public health explanatory theories, models and frameworks that exclude sexual orientation and gender diversity as dimensions of power that interlock with those of socio-economic, race and ethnicity. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality

Care of Transgender Individuals in India: A Clinical Perspective

Article

Full-text available

Dec 2020

India is making rapid strides in recent times in recognizing and providing legal supports to the transgender community. An increasing number of individuals are seeking medical assistance for gender‑affirming medical interventions. Many medical and surgical practitioners working with transgender clients in the Indian subcontinent face clinical and social challenges. In this article, we highlight some of the common challenges experienced by healthcare professionals and the solutions adopted in providing care for transgender clients.

Psychiatric disorders in female psychosexual disorders—a nationwide, cohort study in Taiwan: Psychiatric disorders and female psychosexual disorders

Article

Full-text available

Jan 2021
BMC PSYCHIATRY

We aimed to investigate whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2240 enrolled individuals, with 560 patients with psychosexual disorders and 1680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000 and 2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the non-cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI = 7.298 — 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in patients with psychosexual disorders.

Psychiatric Disorders in Female Psychosexual Disorders—A Nationwide, Cohort Study in Taiwan

Preprint

Full-text available

Jul 2020

We aimed to investigate as to whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2,240 enrolled individuals, with 560 patients with psychosexual disorders and 1,680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000-2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI= 7.298 — 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in the patients with psychosexual disorders.

Gender dysphoria in Saudi Arabia

Article

May 2021

Gender dysphoria is defined as a multisystemic medical condition where a person has marked discordance between their biological sex and the gender they identify with. Here we report a case of 44-year-old male who presented to the family medicine clinic as a known case of gender dysphoria. Patient was severely distressed about his life and was actively seeking a solution to his problem. The patient requested that the treating physician addresses him as a female and uses feminine proverbs while speaking with him. On examination of genitalia, testicles were smaller than normal for his age and sex. Several abnormalities were found including low levels of testosterone, luteinizing hormone, and follicle-stimulating hormone, and elevated prolactin levels. Abdominal and pelvic ultrasound showed that the internal organs were all normal size and consistency. No uterus, ovaries or rudimentary female reproductive organs were found. Testicular ultrasound revealed atrophy of both testicles and weak peripheral testicular vascularity were noted. CT scan with contrast revealed severe hepatic steatosis as well as bilateral gynecomastia. Primary care physicians need to be aware of gender-related disorders as well as the importance of early recognition of these emerging disorders. A multidisciplinary approach is needed to manage these disorders.

Effectiveness of vocal therapy versus thyroplasty in the voice of transgender women: an integrative review

Article

Full-text available

Aug 2021

Introducción. Las mujeres transgénero encuentran frecuentemente problemas en ajus-tar su voz a la frecuencia femenina. Para favorecer el cambio vocal deseado por estos in-dividuos, se ofrecen dos técnicas: una quirúrgica (tiroplastía) y otra clínica (terapia vocal). Objetivo. Esta revisión integrativa pretende verificar las publicaciones científicas relacionadas con las dos técnicas, observando cuál reporta mayor efectividad. Método. Se realizó una búsqueda en bases de datos, considerando las palabras clave: Transsexual Persons AND Voice Feminization AND Thyroplasty OR Voice Training. Resultados. Nueve artículos corresponden a estudios observacionales y tres utiliza-ron una metodología cuasi experimental. Los grupos estudiados incluyen un amplio espectro etario. Ninguno de los estudios informa aspectos económicos de las inter-venciones. No existe evidencia de seguimiento a largo plazo. Conclusiones. La vía de tratamiento vocal con adición hormonal puede ser una primera línea, y en caso de no reportar mejoras, la cirugía aparece como otra opción. Recomendación. La recomendación es que se realice terapia vocal, que no im-plica riesgos significativos de complicaciones, siendo además un abordaje relativa-mente económico. Palabras clave Transgéneros; calidad vocal; entrenamiento vocal; laringoplastía; tiroplastía; vocolo-gía; fonoaudiología; voz. Abstract Introduction. Transsexual women frequently encounter problems in adjusting their voices to the characteristics of their new gender. In order to help in the change to the desired voice, two techniques are often used: the surgical (Thyroplasty) and clinical (Speech Therapy).

The gender-affirmative life span approach: A developmental model for clinical work with transgender and gender-diverse children, adolescents, and adults

Article

Mar 2021
PSYCHOTHERAPY

The gender-affirmative life span approach (GALA) is an innovative therapeutic framework for promoting the mental health of transgender and gender-diverse (TGD) clients of all ages. Based in interdisciplinary philosophical foundations, GALA proposes that TGD clients can be supported in psychotherapy through (a) developing gender literacy, (b) building resiliency, (c) moving beyond the binary, (d) exploring pleasure-oriented sexuality, and (e) making connections to medical interventions. Psychotherapy incorporating these 5 core components is developmentally tailored for children, adolescents, young adults, or older adults. Developing gender literacy is the process of understanding how sex assigned at birth, gender identity, gender expression, and sexual orientation are distinct but interconnected concepts, as well as learning to identify oppressive practices in TGD people's lives. Building resiliency involves learning how to overcome adversity and effectively cope with challenging situations in life. Resiliency-building also involves having social support networks to share these difficulties and gain support. Gender and sexual binaries pathologize nonconformity and limit the full range of healthy gender and sexual expression. Moving beyond the binary to a spectrum approach allows for the inclusion and affirmation of all gender identities and expressions. Unfortunately, research and practice have largely focused on negative sexual outcomes for TGD people. Thus, age-appropriate psychotherapy aimed at developing sex-positive pleasure and satisfaction is critical. Lastly, gender-competent mental health practitioners need to have knowledge about, and skills to refer for, medical interventions, when appropriate. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Health Care Needs Assessment of Gender Identity Services (Scotland)

Technical Report

Full-text available

May 2018

ScotPHN has undertaken a national needs assessment of gender identity services in Scotland. The national healthcare needs assessment has been informed by discussions with third sector organisations and NHS Boards. The work has been guided by a small project group whose membership includes representation from The Scottish Trans Alliance, LGBT Youth, LGBT Health & Well-being and Stonewall Scotland. The working project brief is available here: https://www.scotphn.net/projects/gender-re-assignment/introduction/

Is It Autism? A Critical Commentary on the Co- Occurrence of Gender Dysphoria and Autism Spectrum Disorder

Article

Apr 2021
J HOMOSEXUAL

An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to pro- vide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two condi- tions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at deal- ing with socio-relational and identity problems are discussed.

A Response to Jue et al, “Kidney Transplantation in Transgender Patients”

Article

Full-text available

May 2021
Curr Urol Rep

Microaggressions towards lesbian and transgender women: Biased information gathering when working alongside gender and sexual minorities

Article

Full-text available

May 2021
J CLIN PSYCHOL

Objective Microaggressions, a concept originally introduced for ethnic minorities, represent subtle day‐to‐day discrimination, damaging the psychological health and well‐being of lesbian, gay, bisexual, and transgender individuals as well. This study aimed to assess whether microaggressions occur in psychotherapists’ assessments of clients who identify as either lesbian or transgender woman when compared with those identifying as heterosexual woman. Methods The study included a sample of 135 licensed psychotherapists (110 cisgender women and 25 cisgender men). Participants were presented with an audio file of a woman introducing herself during her first therapy session. Three versions were presented: a transgender, a lesbian, and a heterosexual client. Participants were asked to assess the clinical relevance of 10 questions defined as neutral (N = 5) and microaggressive (N = 5), used to determine a clinical impression of the client. A repeated measure analysis of variance was conducted to understand the likelihood of clients of different gender identity and sexual orientation receiving microaggressions. Results Participants were more prone to consider microaggressive questions relevant where the client identified as either lesbian or transgender. Conclusions The findings highlighted a bias against lesbian and trans women in evaluating the relevance and usefulness of clinical information while making a psychological assessment of a case.

Psychological Functioning in Non-binary Identifying Adolescents and Adults

Article

Full-text available

Aug 2021
J SEX MARITAL THER

Gender diverse individuals who do not conform to society’s binary gender expectations are more likely to experience difficulties in acceptance and in recognition of gender, compared to binary-identifying transgender people. This may accentuate the feeling that their gender identity is not socially recognized or validated. This study aimed to investigate psychological functioning among gender diverse adolescents and adults who identify beyond the binary gender spectrum. In both study populations, 589 clinically-referred gender diverse adolescents from the UK (n = 438 birth-assigned females and n = 151 birth-assigned males), and 632 clinically-referred gender diverse adults from the Netherlands (n = 278 birth-assigned females and n = 354birth-assigned males), we found that a higher degree of psychological problems was predicted by identifying more strongly with a non-binary identity. For adolescents, more psychological problems were related to having a non-binary gender identity and being assigned female at birth. In the adult population, experiencing psychological difficulties was also significantly related to having a stronger non-binary identity and having a younger age. Clinicians working with gender diverse people should be aware that applicants for physical interventions might have a broader range of gender identities than a binary transgender one, and that people with a non-binary gender identity may, for various reasons, be particularly vulnerable to psychological difficulties.

Issues in Working with Transgender Individuals Who Sexually Harm

Article

Full-text available

Jul 2021
Curr Psychiatr Rep

Shan Jumper

Purpose of Review I review the recent literature related to the assessment, treatment, and management of transgender individuals who sexually harm. Recent Findings There are no empirical research studies directly focused on the care of this group of individuals that have only recently been identified as an important sub-population among people who sexually harm. Related empirical research and other important professional literature do exist to inform clinicians regarding treatment guidelines for transgender mental healthcare. Summary Research is needed to determine how best to assess sexual violence recidivism risk and to distinguish unique treatment needs for transgender individuals who sexually harm. Strength-based approaches to the treatment of sexual violence can help organize treatment approaches to assist transgender individuals in avoiding future incidents of sexually harmful behavior.

The Experience of Gender Incongruity in the Christian Church: A Qualitative Study

Article

Full-text available

May 2021
J Relig Health

This study was designed to understand the interaction between Christian faith and gender incongruence. An anonymous online survey was advertised to the Australian Christian community. Individuals with first-hand experience of transgender issues were eligible to participate. There were 122 eligible responses. This paper describes the experience of the 30 participants experiencing gender incongruence. Persons in the church experiencing gender incongruence desired to hold onto faith. As a result, they experienced a tension between the desire to remain in the church, and the desire to live congruously with their gender, which could lead to expulsion. Strategies to reconcile these two factors varied.

Mental health concerns and barriers to care among future clinical psychologists

Article

Jun 2021
J CLIN PSYCHOL

Few studies have examined the mental health of clinical psychology doctoral students, a unique group given their education and training in psychopathology, assessment, and intervention. Students (N = 912) completed an online survey assessing demographics, mental health, mental healthcare utilization, and barriers to care during graduate school. Nearly 25% of participants reported moderate to severe symptoms of anxiety, 20% reported moderate to severe symptoms of depression or suicidal intent (SI), and more than 10% reported a high risk of alcohol abuse or moderate to severe drug use during graduate school. In comparison to peers, ethnic minority and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) participants reported more symptoms of depression and SI. LGBTQ+ participants reported more nonsuicidal self-injury and drug use. Participants also experienced significant barriers to receiving mental healthcare (e.g., financial difficulties, limited availability, insufficient time). Leadership is encouraged to prioritize the mental health of clinical psychology doctoral students, which may have implications on their service provision.

Selective Estrogen Receptor Modulators: A Potential Option For Non-Binary Gender-Affirming Hormonal Care?

Article

Full-text available

Jun 2021

Gender dysphoria describes the distress associated with having a gender identity that differs from one’s birth-assigned sex. To relieve this distress, transgender, and gender diverse (henceforth, trans) individuals commonly undergo medical transition involving hormonal treatments. Current hormonal treatment guidelines cater almost exclusively for those who wish to transition from male to female or vice versa. In contrast, there is a dearth of hormonal options for those trans individuals who identify as non-binary and seek an androgynous appearance that is neither overtly male nor female. Though prolonged puberty suppression with gonadotrophin releasing hormone agonists (GnRHa) could in theory be gender-affirming by preventing the development of unwanted secondary sex characteristics, this treatment option would be limited to pre- or peri-pubertal adolescents and likely have harmful effects. Here, we discuss the theoretical use of Selective Estrogen Receptor Modulators (SERMs) for non-binary people assigned male at birth (AMAB) who are seeking an androgynous appearance through partial feminization without breast growth. Given their unique range of pharmacodynamic effects, SERMs may represent a potential gender-affirming treatment for this population, but there is a lack of knowledge regarding their use and potentially adverse effects in this context.

Parcours de transition et bien-être psychosocial des personnes trans, non-binaires ou en questionnement identitaire de genre - Premier volet des résultats d'une enquête québécoise

Research

Full-text available

Jul 2021

The lived experience of gender dysphoria in autistic adults: An interpretative phenomenological analysis

Article

Jul 2021

Characteristics and expectations of patients seeking help for gender dysphoria in one of the sexological outpatient clinics in Poland.

Article

Full-text available

Jul 2021
PSYCHIATR POL

Short-Term Effects of Gender-Affirming Hormone Therapy on Dysphoria and Quality of Life in Transgender Individuals: A Prospective Controlled Study

Article

Full-text available

Jul 2021

Gender affirming hormone therapy (GAHT), whilst considered the standard of care in clinical guidelines for the treatment of many transgender (trans) people is supported by low quality evidence. In this prospective longitudinal controlled study, we aimed to examine the effect of newly commencing GAHT on gender dysphoria and quality of life (QoL) over a 6 month period. Adult trans (including those with binary and/or non-binary identities) people newly commencing standard full-doses of masculinising (n = 42; 35 = trans masculine, 7 = non-binary) or feminising (n = 35; 33 = trans feminine, 2 = non-binary) GAHT and cisgender participants (n=53 male, n=50 female) were recruited to participate in this longitudinal prospective study. This analysis of gender dysphoria measured by the Gender Preoccupation and Stability Questionnaire and QoL measured by the RAND Short-Form 36 Health survey at baseline, 3 and 6 months after commencement of GAHT was a prespecified secondary outcome. Dysphoria and QoL over time in those starting GAHT compared to cisgender comparison group matched for their presumed sex at birth is reported as the mean difference (95% confidence interval) adjusted for age. In trans people initiating masculinising GAHT, there was a decrease in gender dysphoria with adjusted mean difference -6.80 (-8.68, -4.91), p < 0.001, and a clinically significant improvement in emotional well-being [adjusted mean difference 7.48 (1.32, 13.64), p = 0.018] and social functioning [adjusted mean difference 12.50 (2.84, 22.15), p = 0.011] aspects of QoL over the first 6 months of treatment relative to the cisgender female comparison group. No significant differences were observed in other QoL domains. In trans people initiating feminising GAHT, there was a decrease in gender dysphoria [adjusted mean difference -4.22 (-6.21, -2.24), p < 0.001] but no differences in any aspects of QoL were observed. In the short-term, our findings support the benefit of initiating masculinising or feminising GAHT for gender dysphoria. Masculinising GAHT improves emotional well-being and social functioning within 6 months of treatment. Multidisciplinary input with speech pathology and surgery to support trans people seeking feminisation is likely needed. Further longitudinal studies controlled for other confounders (such as the presence of social supports) contributing to QoL are needed.

Undergoing pregnancy and childbirth as trans masculine in Sweden: experiencing and dealing with structural discrimination, gender norms and microaggressions in antenatal care, delivery and gender clinics

Article

Full-text available

Dec 2020

Background A sterilization requirement to change legal gender was removed from Swedish law in 2013, facilitating pregnancy in trans masculine individuals. The limited number of studies investigating pregnancy and childbirth among trans masculine individuals indicate increased gender dysphoria and negative experiences of pre- and post-natal healthcare, highlighting a need to improve care. Research focusing on Europe or contexts where sterilization to change legal gender was previously required by national law remains minimal. Aims This study aimed to investigate how trans masculine individuals experience healthcare encounters in connection with pregnancy, delivery and nursing, in a setting where mandatory sterilization to change legal gender was recently removed. Methods In-depth face-to-face interviews were conducted with 12 trans masculine individuals who attended Swedish prenatal care and delivered a child after the law on legal gender recognition was amended. Thematic content analysis was used. Results Providers in gender clinics, antenatal care and delivery were perceived to regard a masculine gender identity and pregnancy as incompatible. The main categories encompassed expectations and experiences of pregnancy related care and participant responses to it. Participants took charge of their care to ensure that their needs were fulfilled. The quality of care was inconsistent. Discussion A lack of knowledge, narrow gender norms and the legacy of the former legal sterility requirement limited access to diagnostic evaluation of gender dysphoria, information on reproduction and gender-affirming treatment. Medical safety during pregnancy, childbirth and nursing was impeded, gender dysphoria increased, and participants experienced minority stress. Attempts to avoid microaggressions guided healthcare encounters and birth wishes. Navigating healthcare required considerable attention, personal resources and energy, leaving particularly vulnerable individuals at risk of a lower quality of care. The paper concludes with clinical recommendations.

Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians

Article

Feb 2021
INT J IMPOT RES

Hypoactive sexual desire disorder (HSDD) represents a common condition among transgender women. However, to date no specific guidelines for the management of HSDD in transgender persons are available. The aim of the present narrative Review is to evaluate evidence-based treatment for HSDD and to suggest treatment options for HSDD in transgender women. Clinically relevant publications on the management of HSDD (from 1985 to 2020) were searched in PubMed and Medline databases, using the following terms: “sexual desire”, “sexual health”, “HSDD”, “transgender”, “gender-affirming treatment”, “sexual therapy”, “testosterone treatment”, “Central nervous system-active medications”, and variants. Since sexual desire could be affected by several factors, a comprehensive assessment of HSDD- exploring biological, psychological, and social domains- is recommended, in order to identify possible predisposing, precipitating and maintaining factors. Among treatment options, transgender women may benefit of different sex therapy strategies and/or central nervous system-active medications—such as flibanserin, bremelanotide, bupropion and buspirone—and transdermal testosterone, bearing in mind that this option could be poorly accepted by patients due to the risk of virilizing effects. The lack of data regarding the efficacy of HSDD treatment options in transgender women emphasize the need for literature to focus more on this topic in the future.

TGNB persons, mental health, and gender binarism in Serbia

Article

Dec 2020
J Gay Lesb Ment Health

Background There are for the time being no systematic studies exploring transgender and non-binary (TGNB) mental health in the Serbian context which, over the last three decades, has been characterized by profound social transformations. Method We draw upon 15 semi-structured interviews with members of a TGNB self-help group operating in Belgrade, Serbia. The material was analyzed using inductive thematic analysis. Results We identified three elements of group operation: 1) information, support, and community, 2) navigating the medical/psychiatric system, and 3) dealing with gender binarism. While the group is important for helping its members navigate the medical system in terms of mental health professionals’ expectations regarding “proper” candidates for gender affirmation procedures, it has a hard time escaping a gender binarism that characterizes its social context. Conclusions Despite significant improvements in the situation of TGNB people concerning psychiatric gatekeeping and legal gender recognition, the TGNB community is still marginalized with mental health being one of the main areas of marginalization. Activist organizations’ alternative forms of mental health care can help to transform mainstream mental health policies rendering them more sensitive to the needs of TGNB individuals.

Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity

Article

Full-text available

Dec 2020

Individuals with gender incongruence (GI) experience serious distress due to incongruence between their gender identity and birth-assigned sex. Sociological, cultural, interpersonal, and biological factors are likely contributory, and for some individuals medical treatment such as cross-sex hormone therapy and gender-affirming surgery can be helpful. Cross-sex hormone therapy can be effective for reducing body incongruence, but responses vary, and there is no reliable way to predict therapeutic outcomes. We used clinical and MRI data before cross-sex hormone therapy as features to train a machine learning model to predict individuals’ post-therapy body congruence (the degree to which photos of their bodies match their self-identities). Twenty-five trans women and trans men with gender incongruence participated. The model significantly predicted post-therapy body congruence, with the highest predictive features coming from the cingulo-opercular (R² = 0.41) and fronto-parietal (R² = 0.30) networks. This study provides evidence that hormone therapy efficacy can be predicted from information collected before therapy, and that patterns of functional brain connectivity may provide insights into body-brain effects of hormones, affecting one's sense of body congruence. Results could help identify the need for personalized therapies in individuals predicted to have low body-self congruence after standard therapy.

Testosterone therapy masculinizes speech and gender presentation in transgender men

Article

Full-text available

Feb 2021

Voice is one of the most noticeably dimorphic traits in humans and plays a central role in gender presentation. Transgender males seeking to align internal identity and external gender expression frequently undergo testosterone (T) therapy to masculinize their voices and other traits. We aimed to determine the importance of changes in vocal masculinity for transgender men and to determine the effectiveness of T therapy at masculinizing three speech parameters: fundamental frequency (i.e., pitch) mean and variation ( f o and f o -SD) and estimated vocal tract length (VTL) derived from formant frequencies. Thirty transgender men aged 20 to 40 rated their satisfaction with traits prior to and after T therapy and contributed speech samples and salivary T. Similar-aged cisgender men and women contributed speech samples for comparison. We show that transmen viewed voice change as critical to transition success compared to other masculine traits. However, T therapy may not be sufficient to fully masculinize speech: while f o and f o -SD were largely indistinguishable from cismen, VTL was intermediate between cismen and ciswomen. f o was correlated with salivary T, and VTL associated with T therapy duration. This argues for additional approaches, such as behavior therapy and/or longer duration of hormone therapy, to improve speech transition.

High court should not restrict access to puberty blockers for minors

Article

Feb 2021
J MED ETHICS

Cameron Beattie

Gender dysphoria (GD) is a clinically significant incongruence between expressed gender and assigned gender, with rapidly growing prevalence among children. The UK High Court recently conducted a judicial review regarding the service provision at a youth-focussed gender identity clinic in Tavistock. The high court adjudged it ‘highly unlikely’ that under-13s, and ‘doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for GD. They based their reasoning on the limited evidence regarding efficacy, the likelihood of progressing to cross-sex hormone therapy and the ‘life-changing consequences’ of puberty blockers. In this article, I offer two concurrent arguments to dispute their reasoning. First, I argue that minors can be competent to consent to puberty blockers for GD, because the decision to undergo puberty blocker therapy is no more complex or far-reaching than other medical decisions that we accept a child should be able to make. Second, I argue that—irrespective of competence—such legal restriction for all children fundamentally contradicts the central ethical tenet of child healthcare: best interests. For these two reasons, the high court should not restrict access to puberty blockers for competent GD children.

Tai Chi, Qigong and Transgender Health

Preprint

Full-text available

Apr 2021

Gender Dysphoria in Men

Chapter

Mar 2021

Jaco Erasmus

Physical, Mental and Sexual Health Among Transgender Women: A Comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network

Article

Mar 2021
J SEX MED

Background Few studies have investigated how physical, mental and sexual function are associated with each other in operated transgender women (oTW). Aim To provide information on the physical, mental and sexual health of oTW in comparison with a group of cisgender women (cisW). Methods An age-matched control study was carried out, recruiting 125 oTW in 7 national referral centers and 80 volunteer women. Beck Depression Inventory Primary Care (BDI-PC), General Health Survey (SF-36), Female Sexual Function Index (FSFI) and operated Male to Female Sexual Function Index (oMtFSI) questionnaires were web-based administered. Data included: age, area of origin, educational level, sexual orientation, years since surgery and hormone therapy. Outcomes T-test was applied to inspect mean score differences between oTW and cisW, in mental, sexual and physical health; simple correlations and multiple regression analysis revealed how mental, sexual and physical health were concurrently associated in the two groups Results Response rate 60% (52% oTW, 71% cisW). oTW mean age 38.5 years (SD = 9.3), cisW 37.7 years (SD = 11.5). Both cisW and oTW reported average values in the range of mental, physical and sexual health. Statistical comparisons revealed no significant group differences in mental and physical health. oTW who referred a worse sexual function also reported worse overall mental well-being and higher levels of depressive symptoms. FSFI scores were negatively associated with years since surgery, but not with age. Multiple regression analysis showed that FSFI Pain accounted for a significant unique variance proportion of risk of depression in oTW. FSFI Sexual Pain was the strongest estimator of inter-individual differences in BDI-PC among oTW (P < .01). Clinical Implications No significant differences in the levels of depressive symptoms, physical and mental well- being were found in oTW and cis-W. The relation between depressive symptoms and sexual function in oTW is stronger than in cisW, and sexual pain substantially predicts risk of depression in oTW. Strengths & Limitations The evaluation of outcomes using validated questionnaires and the relatively large sample size. The convenience control group reported mental, physical and sexual health levels within the range of Italian normative data. Since this is a cross-sectional study, we must be careful in drawing conclusions from our results. Conclusions Sexual pain and lubrication difficulties are the main causes of worse sexual function in oTW, highlighting the importance of perioperative counseling to make surgical expectations realistic and to educate to a proper neovagina management. Vedovo F, Di Blas L, Aretusi F, et al. Physical, Mental and Sexual Health Among Transgender Women. A comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network. J Sex Med Rev 2021;xx:xxx–xxx.

Levels of physical activity and barriers to sport participation in young people with gender dysphoria

Article

Apr 2021
J PEDIATR ENDOCR MET

Objectives To determine the levels of physical activity (PA) in young people with gender dysphoria (GD) and help identify factors which deter participation. Methods Fifty-six young people who attended paediatric endocrinology because of GD, June to October 2019, and were on treatment with gonadotrophin-releasing hormone (GnRH) analogue were approached to participate in a survey. Results A total of 55 young people (98%) responded to the survey. Thirty-eight (69%) participated in PA for >1 h/week. Thirty-two (58%) reported high motivation level for exercise. Those had median age of 15.9 years (10.7, 18.7) at the time of survey, and 13.6 years (9.7, 17.6) at start of GnRH analogue compared to 16.7 years (13.9, 18.5) (p, 0.047) and 15.4 years (11.2, 18.0) (p, 0.009) of the 23 (42%) who reported low motivation. Forty-one (74.5%) reported barriers when accessing PA, such as not being as good as others (75%), revealing sports clothing (73%) and not satisfied with body image (47%). Those were older (16.4 years [10.9, 18.7] vs. 14.7 years [10.7, 18.4] [p, 0.011]) at the time of survey and at start of GnRH analogue (14.9 years [9.7, 18.0] vs. 12.5 years [10.6, 15.2] [p, 0.0001]) than those 14 (25.5%) who reported facing no barriers. Twelve (85.7%) of those reporting no barriers stated high motivation levels compared to 20 (48.8%) of those reporting barriers (p, 0.026). Conclusions Strategies aimed at improving participation are twofold: first to improve motivation, especially in post-pubertal young people, and secondly to achieve societal change to help eliminate barriers.

Tai Chi, Qigong and Transgender Health

Preprint

Full-text available

Apr 2021

Internalized Transphobia, Nondisclosure of Gender Identity, and Life Satisfaction among Gender Minority Adults: The Moderating Roles of Psychological Flexibility and Inflexibility

Article

Apr 2021

Gender minority individuals report higher rates of psychological difficulties and lower levels of life satisfaction compared to the general population. Minority-related stressors are associated with poorer mental health and life satisfaction among gender minority individuals. The aim of the current study was to examine whether psychological flexibility and inflexibility moderated the relationship between two gender minority-related stressors (i.e., internalized transphobia and nondisclosure of gender identity) and life satisfaction. Participants were recruited via advertisements on social media websites (e.g., Facebook), Reddit, and organizations serving gender minorities and 402 participants were included in the statistical analyses. Results showed that both psychological flexibility and inflexibility moderated the relationship between 1) internalized transphobia and life satisfaction and 2) nondisclosure of gender identity and life satisfaction. The current study highlights the need to continue to examine these variables, as well as, investigate the efficacy and effectiveness of interventions that target psychological flexibility and inflexibility on mental health and life satisfaction for gender minority populations.

Transgender People’s Technology Needs to Support Health and Transition

Conference Paper

May 2021

Providing Relationships and Sex Education for Special Learners: An essential guide for developing RSE provision

Book

Jun 2021

Paul Bray

Mental health correlates and potential childhood predictors for the wish to be of the opposite sex in young autistic adults

Article

Jun 2021
AUTISM

Lay abstract: Autistic people/people with autism spectrum disorder are more likely to experience gender dysphoria. However, the possible longitudinal predictors and underlying mechanisms of this co-occurrence are unclear. To fill this knowledge gap, we assessed 88 people with autism spectrum disorder and 42 typically developing individuals at their average ages of 13.0 (baseline, childhood/adolescence) and 20.2 years old (follow-up, adulthood). At follow-up, their endorsement on the item "I wish I was the opposite sex" was used to evaluate gender dysphoric symptoms. We compared mental health symptoms between adults with and without this item endorsement at the follow-up assessment. We explored parent-reported family and autism characteristics-related predictors in childhood/adolescence to this item endorsement in adulthood. We found that more autistic adults reported the wish to be of the opposite sex than did typically developing individuals. Autistic adults who endorsed this item experienced more mental health challenges, more school bullying and cyberbullying, more suicidal ideation, and worse quality of life. Moreover, parent-reported lower family support and more stereotyped/repetitive behaviors during childhood/adolescence predicted the self-reported wish to be of the opposite sex in adulthood in autistic individuals. More attention and support should be provided to autistic people regarding gender development and related mental health and quality of life impact, especially during the transition period to young adulthood.

Lebensqualität nach geschlechtsangleichenden Operationen – eine Übersicht

Article

Jun 2021
HANDCHIR MIKROCHIR P

Zusammenfassung Hintergrund Bei Personen mit Geschlechtsinkongruenz wird eine Verminderung der Lebensqualität durch zahlreiche Studien belegt. Die hohe psychische Belastung führt zu depressiven Erkrankungen, Angststörungen und gegenüber der Normbevölkerung erhöhter Suizidalität. Auch soziale Limitationen führen zu verminderter Lebensqualität. Die Möglichkeit geschlechtsangleichender Operationen wird zunehmend wahrgenommen, stellt jedoch einen radikalen Eingriff in das Leben dieser Patienten dar. Ob die chirurgischen Maßnahmen die Lebensqualität und Lebenszufriedenheit von Transfrauen und Transmännern nachhaltig verbessern, soll in dieser Übersichtsarbeit untersucht werden. Methoden Es erfolgte eine Literaturrecherche in den Datenbanken PubMed, Embase und Cochrane Library. Berücksichtigt wurden Originalarbeiten, welche retro- und prospektiv die Lebensqualität nach geschlechtsangleichenden Operationen untersuchten. Ergebnisse 27 Studien, davon 20 retrospektive und 7 prospektive Studien, wurden berücksichtigt, wobei bei 4 Studien ausschließlich Transmänner, bei 11 Studien ausschließlich Transfrauen und bei 12 Studien beide Geschlechter analysiert wurden. In der Gesamtheit der Arbeiten wurden 1849 Transfrauen und 869 Transmänner untersucht. Die Veränderungen der Lebensqualität wurden in diesen durch verschiedene validierte Fragebögen erfasst. Hierbei zeigte sich eine signifikante Verbesserung der Lebensqualität in physischen, psychischen und sozialen Bereichen. Die gesteigerte Zufriedenheit mit dem eigenen Körper und Geschlecht sowie der Lebensqualität generell konnten ebenfalls nachgewiesen werden. Vermehrte psychische Störungen und erhöhte Sterblichkeit gegenüber der Norm wurden auch nach geschlechtsangleichenden Operationen festgestellt. Im Vergleich zur Normbevölkerung blieb die Lebensqualität transsexueller Personen vermindert. Schlussfolgerung Durch zahlreiche Studien kann belegt werden, dass geschlechtsangleichende Operationen helfen, den Leidensdruck unter Transfrauen und Transmännern zu lindern. Lebenszufriedenheit, Gesundheit und soziale Kontakte werden durch chirurgische Eingriffe in Kombination mit endokrinologischer und psychologischer Therapie verbessert. Die Lebensqualität bleibt dennoch hinter der der Normbevölkerung zurück.

Prostate cancer in transgender women: what does a urologist need to know?

Article

Jun 2021
BJU INT

Objective: To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs. Materials and methods: We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women. Results: Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women. Conclusion: The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

To be Defined or Not to Be? Addressing Internal Questions in the Online Community for Gender Diverse Youth

Conference Paper

Jun 2021

Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action

Article

Jul 2021

Queer Democracy: Desire, Dysphoria, and the Body Politic

Book

Jul 2021

Daniel D. Miller

Psychiatric morbidity adult transgender people in Iran

Article

Oct 2021
J PSYCHIATR RES

Psychiatric morbidity among transgender and gender diverse people is thought to be to an important extent related to socio-cultural intolerance, but such morbidity has been understudied in non-western socio-political contexts. This study aims to report the psychiatric profiles of clients who are seeking gender-affirming treatment in a gender clinic in Iran. All transgender people who were consecutively referred to the Mashhad University of Medical Sciences in Mashhad, Iran, between February 2015 and December 2016 were investigated. Clients were evaluated during at least four sessions when sociodemographic and psychiatric characteristics were collected. Out of 209 clients, 205 were included (transmen (TM), N = 110; transwomen (TW) N = 95). A subset of these were assessed using Structured Clinical Interview based for DSM-5 (n = 154). The mean age of participants was 24.41 (SD = 6.316; range, 15–43). There was no significant difference between transmen and transwomen (p = 0.960); 48% (80 out of 154) of participants were found to have at least one current psychiatric condition currently, and 67% (138 out of 205) during their lifetime. Depressive and trauma- and stressor-related disorders were the most common conditions. Prevalence rates were similar in both genders. In both TM and TW groups, as many as 70% of the clients reported that they had experienced suicidal ideation. These findings are surprisingly similar to those of western studies despite the more extreme difficulties Iranian transgender people face in their lives in a non-western socio-political context.

The Effectiveness of Self‌-Efficacy Training on Promoting Mental Health and Decreasing Ruminating in Divorced Women with Drug-Dependent Husbands

Article

Aug 2021

ali Taghvaeinia

The peculiar case of the standards of care: Ethical ramifications of deviating from informed consent in transgender-specific healthcare

Article

Oct 2020
J Gay Lesb Ment Health

Madeleine Lipshie-Williams

Trans is not a disorder – but should still receive funding [Editorial]

Article

Full-text available

Jul 2015

Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada

Article

Full-text available

Jun 2015
BMC PUBLIC HEALTH

Across Europe, Canada, and the United States, 22-43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact. The Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes. Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks. Among trans Ontarians, 35.1 % (95 % CI: 27.6, 42.5) seriously considered, and 11.2 % (95 % CI: 6.0, 16.4) attempted, suicide in the past year. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10(th) versus 90(th) percentile) was associated with a 66 % reduction in ideation (RR = 0.34, 95 % CI: 0.17, 0.67), and an additional 76 % reduction in attempts among those with ideation (RR = 0.24; 95 % CI: 0.07, 0.82). This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10(th) percentile. Large effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations. Such interventions at the population level may require policy change.

The frequency of personality disorders in patients with gender identity disorder

Article

Full-text available

Apr 2014

Background: Co-morbid psychiatric disorders affect prognosis, psychosocial adjustment and post-surgery satisfaction in patients with gender identity disorder. In this paper, we assessed the frequency of personality disorders in Iranian GID patients. Methods: Seventy- three patients requesting sex reassignment surgery (SRS) were recruited for this crosssectional study. Of the participants, 57.5% were biologically male and 42.5% were biologically female. They were assessed through the Millon Clinical Multiaxial Inventory II (MCMI- II). Results: The frequency of personality disorders was 81.4%. The most frequent personality disorder was narcissistic personality disorder (57.1%) and the least was borderline personality disorder. The average number of diagnoses was 3.00 per patient. Conclusion: The findings of this study revealed that the prevalence of personality disorders was higher among the participants, and the most frequent personality disorder was narcissistic personality disorder (57.1%), and borderline personality disorder was less common among the studied patients.

Psychiatric Axis I Comorbidities among Patients with Gender Dysphoria

Article

Full-text available

Aug 2014

Objectives. Cooccurring psychiatric disorders influence the outcome and prognosis of gender dysphoria. The aim of this study is to assess psychiatric comorbidities in a group of patients. Methods. Eighty-three patients requesting sex reassignment surgery (SRS) were recruited and assessed through the Persian Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Results. Fifty-seven (62.7%) patients had at least one psychiatric comorbidity. Major depressive disorder (33.7%), specific phobia (20.5%), and adjustment disorder (15.7%) were the three most prevalent disorders. Conclusion. Consistent with most earlier researches, the majority of patients with gender dysphoria had psychiatric Axis I comorbidity.

Gender Dysphoria – Prevalence and Co-Morbidities in an Irish Adult Population

Article

Full-text available

Jun 2014

Introduction: Gender dysphoria (GD) is a condition in which there is a marked incongruence between an individual's psychological perception of his/her sex and their biological phenotype. Gender identity disorder was officially renamed "gender dysphoria" in the DSM-V in 2013. The prevalence and demographics of GD vary according to geographical location and has not been well-documented in Ireland. Methods: We retrospectively reviewed medical records of 218 patients with suspected or confirmed GD referred to our endocrine service for consideration of hormonal therapy (HT) between 2005 and early 2014. We documented their demographics, clinical characteristics, and treatment during the study period. Results: The prevalence of GD in the Irish population was 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM), similar to reported figures in Western Europe. 159 of the patients were MTF and 59 were FTM, accounting for 72.9% and 27.1% of the cohort, respectively. The rate of referral has increased year-on-year, with 55 patients referred in 2013 versus 6 in 2005. Mean ages were 32.6 years (MTF) and 32.2 years (FTM). 22 of the patients were married and 41 had children, with 2 others having pregnant partners. 37.6% were referred by a psychologist, with the remainder evenly divided between GPs and psychiatric services. There were low rates of coexistent medical illness although psychiatric conditions were more prevalent, depression being a factor in 34.4% of patients. 5.9% of patients did not attend a mental health professional. 74.3% are currently on HT, and 9.17% have had gender reassignment surgery (GRS). Regret following hormonal or surgical treatment was in line with other Western European countries (1.83%). Conclusion: The incidence of diagnosis and referral of GD in Ireland is increasing. This brings with it multiple social, health, and financial implications. Clear and accessible treatment pathways supported by mental health professionals is essential.

Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder

Article

Full-text available

Oct 2013
J Sex Med

At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 (SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre- and postoperative assessments. A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy. Heylens G, Verroken C, De Cock S, T'Sjoen G, and De Cuypere G. Reassignment therapy on psychopathology: A prospective study of persons with a gender identity disorder. J Sex Med **;**:**-**.

Psychopathological Profiles in Transsexuals and the Challenge of Their Special Status among the Sexes

Article

Full-text available

Nov 2013
PLOS ONE

INVESTIGATING PSYCHOPATHOLOGICAL PROFILES OF TRANSSEXUALS RAISES A VERY BASIC METHODOLOGICAL QUESTION: are control groups, which represent the biological or the phenotypic sex, most suited for an optimal evaluation of psychopathology of transsexuals? Male-to-female (MtF) (n=52) and female-to-male transsexuals (FtM) (n=32), receiving cross-sex hormone treatment, were compared with age matched healthy subjects of the same genetic sex (n=178) and with the same phenotypic sex (n=178) by means of the Symptom Check List-90-Revisited instrument (SCL-90-R). We performed analyses of covariance (ANCOVA) to test for group and sex effects. Furthermore, we used a profile analysis to determine if psychopathological symptom profiles of transsexuals more closely resemble genotypic sex or phenotypic sex controls. Transsexual patients reported more symptoms of psychopathological distress than did healthy control subjects in all subscales of the SCL-90-R (all p<0.001), regardless of whether they were compared with phenotype or genotype matched controls. Depressive symptoms were more pronounced in MtF than in FtM (SCL-90-R score 0.85 vs. 0.45, p = 0.001). We could demonstrate that FtM primarily reflect the psychopathological profile of biological males rather than that of biological females (r = 0.945), while MtF showed a slightly higher profile similarity with biological females than with biological males (r = 0.698 vs. r = 0.685). Our findings suggest that phenotypic sex matched controls are potentially more appropriate for comparison with the psychopathology of transsexual patients than are genetic sex matched controls.

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

Article

Full-text available

Aug 2012

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Psychiatric characteristics in transsexual individuals: Multicentre study in four European countries

Article

Full-text available

May 2013
Br J Psychiatr

Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results. To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder. 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). 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. People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.

Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery

Article

Full-text available

Apr 2006
Sexologies

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population

Article

Full-text available

Mar 2013
Am J Publ Health

Objectives: We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population. Methods: In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations. Results: Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity. Conclusions: Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.

Measures of Clinical Health among Female-to-Male Transgender Persons as a Function of Sexual Orientation

Article

Full-text available

Jan 2013
Arch Sex Behav

The present study examined the sexual orientation classification system that was used in the DSM-IV-TR for categorizing those who met the Gender Identity Disorder diagnostic 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 orientation, sexual identity, symptoms of depression and anxiety, stress (Depression Anxiety Stress Scales), social support (Multidimensional 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 significantly differ by sexual attraction on any mental health variables, 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.

Minding the body: Situating gender identity diagnoses in the ICD-11

Article

Full-text available

Dec 2012
Int Rev Psychiatr

Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.

Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients

Article

Full-text available

Oct 2011

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Cortical Thickness in Untreated Transsexuals

Article

Full-text available

Aug 2012
Cerebr Cortex

Sex differences in cortical thickness (CTh) have been extensively investigated but as yet there are no reports on CTh in transsexuals. Our aim was to determine whether the CTh pattern in transsexuals before hormonal treatment follows their biological sex or their gender identity. We performed brain magnetic resonance imaging on 94 subjects: 24 untreated female-to-male transsexuals (FtMs), 18 untreated male-to-female transsexuals (MtFs), and 29 male and 23 female controls in a 3-T TIM-TRIO Siemens scanner. T1-weighted images were analyzed to obtain CTh and volumetric subcortical measurements with FreeSurfer software. CTh maps showed control females have thicker cortex than control males in the frontal and parietal regions. In contrast, males have greater right putamen volume. FtMs had a similar CTh to control females and greater CTh than males in the parietal and temporal cortices. FtMs had larger right putamen than females but did not differ from males. MtFs did not differ in CTh from female controls but had greater CTh than control males in the orbitofrontal, insular, and medial occipital regions. In conclusion, FtMs showed evidence of subcortical gray matter masculinization, while MtFs showed evidence of CTh feminization. In both types of transsexuals, the differences with respect to their biological sex are located in the right hemisphere.

Perceived discrimination and depression among low-income Latina male-to-female transgender women

Article

Full-text available

Aug 2012
BMC PUBLIC HEALTH

Background This study examines exposure to perceived discrimination and its association with depression among low-income, Latina male-to-female transgender women as well as evaluates the impact of sexual partner violence and mistreatment on depression. Methods A total of 220 Latina male-to-female transgender women who resided in Los Angeles, California, were recruited through community based organizations and referrals. Participants completed individual interviews using a structured questionnaire. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Perceived discrimination was assessed using a fifteen-item measure that was designed to assess the experiences of maltreatment of transgender individuals. Multinomial logistic regression was used to examine the association between perceived discrimination and depression after controlling for the presence of other variables. Results Of the sample, 35% reported significant depressive symptoms (PHQ-9 ≥ 15). Additionally, one-third of the participants indicated that in the two weeks prior to the interviews they had thought either of hurting themselves or that they would be better off dead. The extent of perceived discrimination in this population was extensive. Many of the participants experienced discrimination on a daily basis (14%) or at least once or twice a week (25%) as demonstrated by a positive response to at least 7 of 15 items in the measure of perceived discrimination. Almost six out of ten participants admitted that they had been victims of sexual partner violence. Those who reported more frequent discrimination were more likely to be identified with severe depression. There was also a notable association between self-reported history of sexual partner violence and depression severity. Conclusions A significant association between depression severity and perceived discrimination was identified. How exposure to discrimination leads to increased risk of mental health problems needs additional investigation. Models investigating the association between perceived discrimination and depression among transgender women should include sexual partner violence as a potential confounding variable.

Is Hormonal Therapy Associated with Better Quality of Life in Transsexuals? A Cross-Sectional Study

Article

Full-text available

Dec 2011
J Sex Med

Although the impact of sex reassignment surgery on the self-reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. The objectives of this study were to assess the relationship between hormonal therapy and the self-reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross-sex hormone therapy as well as between transsexuals and the general population (French age- and sex-matched controls). This study incorporated a cross-sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM-IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre-sex reassignment surgery. QoL was assessed using the Short Form 36 (SF-36). The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty-four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF-36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals' QoL, independently of hormonal status, did not differ from the French age- and sex-matched controls except for two subscales of the SF-36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). The present study suggests a positive effect of hormone therapy on transsexuals' QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Childhood maltreatment in subjects with male-to-female gender identity disorder

Article

Full-text available

Aug 2011

Childhood maltreatment (CM) is quite common and constitutes a nonspecific risk factor for a range of different psychiatric symptoms during lifespan. It has been demonstrated that sexual minorities are at higher risk of maltreatment and abuse, and a high proportion of transsexual subjects report CM. The aim of this study is to evaluate the prevalence of reported CM in a clinical sample of patients with male-to-female Gender Identity Disorder (MtF GID), and to explore the relationship between these early life events, body image and different psychopathological and clinical variables. A consecutive series of 162 patients with male genotype was evaluated from July 2008 to May 2010. A total of 109 subjects (mean age 36 ± 10 years) meeting the criteria for MtF GID and giving their informed consent were considered. The occurrence of CM experiences was evaluated through a face-to-face clinical interview. Patients were asked to complete the Body Uneasiness Test and Symptom Checklist-90 Revised. More than one-fourth of patients reported CM. Maltreated subjects reported a higher body dissatisfaction and display a worse lifetime mental health. The presence of reported CM in these patients has relevant psychopathological implications, and therefore should be carefully investigated.

Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden

Article

Full-text available

Feb 2011
PLOS ONE

The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment. To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons. A population-based matched cohort study. Sweden, 1973-2003. All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively. Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]). The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls. Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Effects of cross-sex hormone treatment on emotionality in transsexuals

Article

Full-text available

Jul 2001

The aim of the study was to investigate whether cross-sex hormone treatment in transsexuals affected the intensity of negative and positive emotions in general, and aggressive and sexual feelings in particular. With respect to emotional behavior, changes in non-verbal expressiveness and anger readiness were examined in 47 female-to-male transsexuals (FtMs) and 54 male-to-female transsexuals (MtFs). We were also interested in finding out whether, in FtMs, the rapidly changing testosterone levels in the two-week cycle testosterone treatment had predictable effects on moods, the development of male physical characteristics and sexuality.

Psychopathological profiles in transsexuals and the challenge of their special status among the sexes

Article

Nov 2013
EXP CLIN ENDOCR DIAB

Objective: Investigating psychopathological profiles of transsexuals raises a very basic methodological question: are control groups, which represent the biological or the phenotypic sex, most suited for an optimal evaluation of psychopathology of transsexuals? Method: Male-to-female (MtF) (n = 52) and female-to-male transsexuals (FtM) (n = 32), receiving cross-sex hormone treatment, were compared with age matched healthy subjects of the same genetic sex (n = 178) and with the same phenotypic sex (n = 178) by means of the Symptom Check List-90-Revisited instrument (SCL-90-R). We performed analyses of covariance (ANCOVA) to test for group and sex effects. Furthermore, we used a profile analysis to determine if psychopathological symptom profiles of transsexuals more closely resemble genotypic sex or phenotypic sex controls. Results: Transsexual patients reported more symptoms of psychopathological distress than did healthy control subjects in all subscales of the SCL-90-R (all p < 0.001), regardless of whether they were compared with phenotype or genotype matched controls. Depressive symptoms were more pronounced in MtF than in FtM (SCL-90-R score 0.85 vs. 0.45, p = 0.001). We could demonstrate that FtM primarily reflect the psychopathological profile of biological males rather than that of biological females (r = 0.945), while MtF showed a slightly higher profile similarity with biological females than with biological males (r = 0.698 vs. r = 0.685). Conclusion: Our findings suggest that phenotypic sex matched controls are potentially more appropriate for comparison with the psychopathology of transsexual patients than are genetic sex matched controls.

Gender identity disorders

Article

Jan 1989

D. Anderson

Symptom Checklist-90-Revised

Article

Jan 2010

Interpersonal functioning among individuals with gender dysphoria

Article

Dec 2015
J Clin Psychol

Objectives: Trans people have been found to have high levels of depression. In view of the association between interpersonal problems and depression and the importance of interpersonal skills to navigate the transition of trans people, this study aims to investigate levels of interpersonal problems among treatment-seeking trans men and women, and the role of depression in this association. Method: 104 patients from a UK Gender Identity Clinic and 104 age and gender matched controls completed self-report measures of interpersonal problems and general psychopathology, including depression. Results: Trans people reported significantly higher scores on global interpersonal problems, and in the sociable, supportive, and involved subscales, and lower scores on the too open subscale. Depression accounted for significant differences on IIP global and the subscale open but not on IIP sociable, supportive and involved. Conclusions: Trans individuals present with interpersonal problems, which could potentially increase their vulnerability to mental health problems. Therefore, addressing interpersonal problems may help to prevent the development of depressive symptomatology and facilitate transition.

Trans is not a disorder – but should still receive funding [Editorial]

Article

Jan 2015

Systematic Review and Meta-Analysis of Prevalence Studies in Transsexualism

Article

May 2015
EUR PSYCHIAT

Background: Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data. Methods: Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed. Results: The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years. Conclusions: The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.

Long-Term Follow-Up of Adults with Gender Identity Disorder

Article

Feb 2015
Arch Sex Behav

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants' gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10-24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real?

Article

Jan 2015
PSYCHIAT RES

The Role of Mental Health Professionals in Gender Reassignment Surgeries: Unjust Discrimination or Responsible Care?

Article

Oct 2014
AESTHET PLAST SURG

Objective Recent literature has raised an important ethical concern relating to the way in which surgeons approach people with gender dysphoria (GD): it has been suggested that referring transsexual patients to mental assessment can constitute a form of unjust discrimination. The aim of this paper is to examine some of the ethical issues concerning the role of the mental health professional in gender reassignment surgeries (GRS). Method The role of the mental health professional in GRS is analyzed by presenting the Standards of Care by the World Professional Association of Transgender Health, and discussing the principles of autonomy and non-discrimination. Results Purposes of psychotherapy are exploring gender identity; addressing the negative impact of GD on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; promoting resilience; and assisting the surgeons with the preparation prior to the surgery and the patient’s follow-up. Offering or requesting psychological assistance is in no way a form of negative discrimination or an attack to the patient’s autonomy. Contrarily, it might improve transsexual patients’ care, and thus at the most may represent a form of positive discrimination. To treat people as equal does not mean that they should be treated in the same way, but with the same concern and respect, so that their unique needs and goals can be achieved. Conclusions Offering or requesting psychological assistance to individuals with GD is a form of responsible care, and not unjust discrimination. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer. com/ 00266.

Non-Suicidal Self-Injury in Trans People: Associations with Psychological Symptoms, Victimization, Interpersonal Functioning, and Perceived Social Support

Article

Nov 2014
J Sex Med

IntroductionThere is a paucity of systematic research in the area of non-suicidal self-injury (NSSI) in trans people.AimThe aim of this study was to investigate the prevalence of NSSI in trans people and the associations with intra- and interpersonal problems.Methods Participants were 155 untreated individuals with a diagnosis of transsexualism (according to International Classification of Disease-10 criteria) attending a national gender identity clinic.Main Outcome MeasuresAll participants completed the Self-Injury Questionnaire, the Symptom Checklist-90-Revised, the Rosenberg Self-Esteem Scale, the Hamburg Body Drawing Scale, the Experiences of Transphobia Scale, the Inventory of Interpersonal Problems-32, and the Multidimensional Scale of Perceived Social Support.ResultsThe sample consisted of 66.5% trans women and 33.5% trans men and 36.8% of them had a history of engaging in NSSI. The prevalence of NSSI was significantly higher in trans men (57.7%) compared with trans women (26.2%). Trans individuals with NSSI reported more psychological and interpersonal problems and perceived less social support compared with trans individuals without NSSI. Moreover, the probability of having experienced physical harassment related to being trans was highest in trans women with NSSI (compared with those without NSSI). The study found that with respect to psychological symptoms, trans women reported significantly more intrapersonal and interpersonal symptoms compared with trans men. Finally, the results of the regression analysis showed that the probability of engaging in NSSI by trans individuals was significantly positively related to a younger age, being trans male, and reporting more psychological symptoms.Conclusions The high levels of NSSI behavior and its association with interpersonal and interpersonal difficulties and lack of social support need to be taken into consideration when assessing trans individuals. The effect of cross-sex hormones and sex reassignment surgery on psychological functioning, including NSSI behavior, as part of the transitional journey of trans individuals should be explored in future studies. Claes L, Bouman WP, Witcomb G, Thurston M, Fernandez-Aranda F, and Arcelus J. Non-suicidal self-injury in trans people: Associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support. J Sex Med **;**:**–**.

Cross-sex hormone use, functional health and mental well-being among transgender men ( Toms ) and Transgender Women ( Kathoeys ) in Thailand

Article

Oct 2014
CULT HEALTH SEX

There exists limited understanding of cross-sex hormone use and mental well-being among transgender women and, particularly, among transgender men. Moreover, most studies of transgender people have taken place in the Global North and often in the context of HIV. This exploratory study compared 60 transgender men (toms) with 60 transgender women (kathoeys) regarding their use of cross-sex hormones, mental well-being and acceptance by their family. Participants also completed a dispositional optimism scale (the Life Orientation Test Revised), the Social Functioning Questionnaire and the Short Form Health Survey 36 assessing their profile of functional health and mental well-being. Cross-sex hormones were used by 35% of toms and 73% of kathoeys and were largely unsupervised by health-related personnel. There were no differences in functional health and mental well-being among toms and kathoeys. However, toms currently using cross-sex hormones scored on average poorer on bodily pain and mental health, compared to non-users. Furthermore, compared to non-users, cross-sex hormone users were about eight times and five times more likely to be associated with poor parental acceptance among toms and kathoeys, respectively. This study was the first to compare cross-sex hormone use, functional health and mental well-being among transgender women and transgender men in Southeast Asia.

Gender Abuse, Depressive Symptoms, and Substance Use Among Transgender Women: A 3-Year Prospective Study

Article

Sep 2014
AM J PUBLIC HEALTH

Objectives: We examined the effects of gender abuse (enacted stigma), depressive symptoms, and demographic, economic, and lifestyle factors on substance use among transgender women. Methods: We conducted a 3-year prospective study (December 2004 to September 2007) of 230 transgender women aged 19 to 59 years from the New York Metropolitan Area. Statistical techniques included generalized estimating equations with logistic and linear regression links. Results: Six-month prevalence of any substance use at baseline was 76.2%. Across assessment points, gender abuse was associated with alcohol, cannabis, cocaine, or any substance use during the previous 6 months, the number of days these substances were used during the previous month, and the number of substances used. Additional modeling associated changes in gender abuse with changes in substance use across time. Associations of gender abuse and substance use were mediated 55% by depressive symptoms. Positive associations of employment income, sex work, transgender identity, and hormone therapy with substance use were mediated 19% to 42% by gender abuse. Conclusions: Gender abuse, in conjunction with depressive symptoms, is a pervasive and moderately strong risk factor for substance use among transgender women. Improved substance abuse treatment is sorely needed for this population.

Social Support and Psychological Well-Being in Gender Dysphoria: A Comparison of Patients With Matched Controls

Article

Aug 2014
J Sex Med

Introduction: There is a paucity of research in the area of social support and psychological well-being among people with gender dysphoria. Aims: The present study aimed to investigate levels of social support among individuals with gender dysphoria compared with a matched control group. It also aimed to examine the relationship between social support and psychological well-being. Methods: Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attending a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social networking websites. Main outcome measures: All participants completed measures of social support (Multidimensional Scale of Perceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form 36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI). Results: Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control women, although these differences in levels of social support were no longer significant when SCL depression was controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not significantly predict SCL subscales but did predict both SF subscales and PWI total scores. Conclusions: Trans women perceived themselves to be lacking social support. Given that social support is beneficial to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings have been derived from correlational results, extended research may highlight the value of clinicians helping trans women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge attitudes of nontrans people towards those with gender dysphoria.

Cross-Sex Hormonal Treatment and Body Uneasiness in Individuals with Gender Dysphoria

Article

Dec 2013
J Sex Med

Cross-sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well-being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone. This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms. A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered. Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body-related psychopathology and the Symptom Checklist-90 Revised (SCL-90-R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records. Among the male-to-female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no-CHT group. No significant differences were observed between CHT and no-CHT groups in the female-to-male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no-CHT), or the interaction of these two variables. Moreover, a two-step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI. The differences observed between MtF and FtM individuals suggest that body-related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness. Fisher AD, Castellini G, Bandini E, Casale H, Fanni E, Benni L, Ferruccio N, Meriggiola MC, Manieri C, Gualerzi A, Jannini E, Oppo A, Ricca V, Maggi M, and Rellini AH. Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria. J Sex Med **;**:**-**.

Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study

Article

Jan 2014
PSYCHONEUROENDOCRINO

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

Hormonal Therapy Is Associated With Better Self-esteem, Mood, and Quality of Life in Transsexuals

Article

Nov 2013
J Nerv Ment Dis

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater "psychological-like" dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Depression in Trans People: A Review of the Risk Factors

Article

May 2012

Nooshin Khobzi Rotondi

Depression is a commonly occurring syndrome characterized by mood-related symptoms; however, it is understudied among trans people (transgender, transsexual, or transitioned). A review of the existing literature on depression revealed eight factors pertinent to trans communities including discrimination, disclosure, identity support, hormones and sex-reassignment surgeries, sociodemographics, socioeconomic factors, substance use, and access to health and social services. This report demonstrates that depression in trans people is a multifaceted condition, which is not easily explained by a single factor. Developing an understanding of such complexities may open the door to more sensitive and appropriate mental health care for trans people.

Gender Identity Conflict/Affirmation and Major Depression Across the Life Course of Transgender Women

Article

May 2012

Using the Life Chart Interview, a validated instrument for the collection of biographical data, lifetime information about transgender experiences was collected in a community-based sample of 571 transgender women from the New York metropolitan area. Disclosures of transgender identity in different types of relationships, responses of relationship partners indicative of gender identity conflict or affirmation, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression were assessed within and across five stages of the life course. Gender identity conflict/affirmation was associated with major depression within stages of the life course (contemporaneous analysis) and predictive of changes in major depression across stages of the life course (lagged analysis).

Prevalence of Childhood Trauma in a Clinical Population of Transsexual People

Article

Mar 2005

Few studies have focused on the prevalence and extent of childhood trauma in the transsexual population. In our study of 42 transsexual people (34 = natal males, 8 = natal females), 55% (n = 23) reported experiencing an unwanted sexual event before the age of 18, with the average age of initial sexual contact being 13. This sexual event differs from other clinical populations in that the unwanted sexual experiences in this sample were the consequence of adolescents satisfying their curiosity about the gender of the transsexual rather than for their own sexual gratification. Consequently, the sequalae of the unwanted sexual touches in our sample did not lead to sexualised behaviours described in the sexual abuse literature of clinical samples. Our sample also reported being: verbally abused (77%), insulted (81%), embarrassed in front of others (55%), made to feel guilty by their parents (58%) before their fifteenth birthday.

The Ten Tasks of the Mental Health Provider: Recommendations for Revision of the World Professional Association for Transgender Health's Standards of Care

Article

Jul 2009

Arlene Lev

This article outlines recommendations for the World Professional Association for Transgender Health's (WPATH) Standards of Care (SOC) regarding the roles, responsibilities, and tasks of the mental health provider in assessing eligibility and readiness for medical and surgical treatment of gender nonconforming, transgender, and transsexual clients. It reflects a reconceptualization of the role of the mental health provider as a gender specialist and an advocate and educator for transgender people and their families utilizing a nonpathologizing assessment process. This article reflects a need for clinical SOC that minimize the role of “gatekeeping,” and increase the use of informed consent and harm-reduction procedures, while still providing guidelines for psychosocial evaluation. Recommendations are made for less pathologizing nomenclature, clearer definitions for the professional qualifications of those specializing in working with gender-variant people, and increased collaboration across disciplines. Suggestions are made for the SOC to recognize greater diversity in gender expression and identity, increased focus on the families and occupational environments of transgender people, and a broader view of gender issues throughout the lifecycle. Guidelines for psychosocial assessment and referral letters to physicians are outlined, including proposals to revisit the professional qualifications of letter writers and the need for two letters for surgical assessment. It is suggested that WPATH take leadership in the training and credentialing of gender specialists. These recommendations require a reorganization of the format of the SOC that will create a state-of-the-art standard of health care for transgender, transsexual, and gender nonconforming people and ensure the provision of high-quality clinical services for those individuals and their families.

Hormonal Treatment Reduces Psychobiological Distress in Gender Identity Disorder, Independently of the Attachment Style

Article

Apr 2013
J Sex Med

IntroductionGender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic-pituitary-adrenal system dysregulation and subjective stress. AimThe objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern. Methods We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers. Main Outcome MeasuresWe used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self-reported perceived stress and the Adult Attachment Interview to determine attachment styles. ResultsAt enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P<0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P<0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P<0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment. Conclusion Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be. Colizzi M, Costa R, Pace V, and Todarello O. Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. J Sex Med 2013;10:3049-3058.

Diagnostic and Statistical Manual of Mental Disorders: DSM-V

Book

Jan 1994

APA American Psychiatric Association

Sociodemographic and Clinical Features of Gender Identity Disorder: An Italian Multicentric Evaluation

Article

Nov 2012
J Sex Med

Introduction. Male to female (MtFs) and female to male (FtMs) subjects with gender identity disorder (GID) seem to differ with regard to some sociodemographic and clinical features. Currently, no descriptive studies focusing on MtFs and FtMs attending an Italian clinic are available. Aim. To describe the sociodemographic characteristics of a GID population seeking assistance for gender transition and to assess possible differences in those features between MtFs and FtMs. Methods. A consecutive series of 198 patients was evaluated for gender dysphoria from July 2008 to May 2011 in four dedicated centers. A total of 140 subjects (mean age 32.6 ± 9.0 years old) meeting the criteria for GID, with their informed consent and without genital reassignment surgery having already been performed, were considered (92 MtFs and 48 FtMs). Diagnosis was based on formal psychiatric classification criteria. Main Outcome Measures. Medical history and sociodemographic characteristics were investigated. Subjects were asked to complete the Body Uneasiness Test (a self-rating scale exploring different areas of body-related psychopathology), Symptom Checklist-90 Revised (a self-rating scale to measure psychological state), and the Bem Sex Role Inventory (a self-rating scale to evaluate gender role). The presence of psychiatric comorbidities was evaluated using the Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (SCID I and SCID II). Results. Several significant differences were found between MtFs and FtMs regarding lifestyle and sociodemographic factors and in psychometric test scores. No differences were found in terms of psychiatric comorbidity. Conclusions. This is the first large study reporting the sociodemographic characteristics of a GID sample referring to Italian clinics, and it provides different profiles for MtFs and FtMs. In particular, FtMs display significantly better social functioning. Fisher AD, Bandini E, Casale H, Ferruccio N, Meriggiola MC, Gualerzi A, Manieri C, Jannini E, Mannucci E, Monami M, Stomaci N, Delle Rose A, Susini T, Ricca V, and Maggi M. Sociodemographic and clinical features of gender identity disorder: An Italian multicentric evaluation. J Sex Med **;**:**–**.

Psychological functions in male-to-female transsexual people before and after surgery

Article

May 2008

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesised that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Symptom Checklist‐90‐Revised

Chapter

Jan 2010

The Symptom Checklist-90-Revised (SCL-90-R) is a 90-item self-report symptom inventory developed by Leonard R. Derogatis in the mid-1970s to measure psychological symptoms and psychological distress. It is designed to be appropriate for use with individuals from the community, as well as individuals with either medical or psychiatric conditions. The SCL-90-R assesses psychological distress in terms of nine primary symptom dimensions and three summary scores termed global scores. The principal symptom dimensions are labeled Somatization (SOM), Obsessive-Compulsive (OBS), Interpersonal Sensitivity (INT), Depression (DEP), Anxiety (ANX), Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR), and Psychoticism (PSY). The global measures are referred to as the Global Severity Index (GSI), the Positive Symptom Distress Index (PSDI), and the Positive Symptom Total (PST). Keywords: assessment; diagnostic methods; self-reports; testing

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)

Chapter

Jan 2000

Structured clinical interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition

Chapter

Jan 2002

Hormone-treated transsexuals report less social distress, anxiety and depression

Article

Sep 2011
PSYCHONEUROENDOCRINO

The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F=4.362, p=.038; F=14.589, p=.001; F=9.523, p=.002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Clinical characteristics of a total cohort of female and male applicants for sex reassignment: A descriptive study

Article

Mar 1998
ACTA PSYCHIAT SCAND

The objective of this study was to compare the features of female-to-male transsexuals (F-M) with those of male-to-female transsexuals (M-F) in the cohort of all applicants for sex reassignment over a 20-year period. In an observational, cross-sectional design the cohort was retrospectively identified, consisting of all 233 subjects who applied for sex reassignment in Sweden during the period 1972-1992. The cohort was subdivided into the groups M-F (n=134) and F-M (n=99), and the two groups were compared. M-F were older when applying for sex reassignment surgery than F-M, and more often had a history of marriage and children than their F-M counterparts. M-F also had more heterosexual experience. F-M, on the other hand, more frequently exhibited cross-gender behaviour in childhood than did M-F transsexuals. The present and previous studies strongly support the view that transsexualism manifests itself differently in males and females. Various models for understanding these differences are discussed.

Dysfunctional core beliefs, perceived parenting behavior and psychopathology in gender identity disorder: A comparison of male-to-female, female-to-male transsexual and nontranssexual control subjects

Article

Mar 2011

Research into the association between Gender Identity Disorder (GID) and psychological disturbances as well as on its relation with parenting experiences yielded mixed results, with different patterns for Male-to-Female (MF) and Female-to-Male (FM) transsexual subjects. We investigated vulnerability markers of maladjustment and their possible origins in MF and FM transsexuals by examining maladaptive core beliefs and parenting behaviors thought to be specifically related to them. Dysfunctional core beliefs, parenting experiences and psychiatric symptoms were assessed by the Young Schema Questionnaire indexing 19 Early Maladaptive Schemas (EMS), the Young Parenting Inventory and the Symptom Checklist-90-R, respectively, in 30 MF, 17 FM transsexual and 114 control subjects (43 males, 114 females). Subjects with GID demonstrated a level of psychiatric distress comparable to that of controls. They did display elevated scores, however, on multiple EMSs compared to nontranssexual subjects, indicating feelings of isolation, emotional deprivation and an urge to meet others' needs, with MF transsexuals conceptualizing themselves also as more vulnerable and deficient than controls. Parenting experiences of transsexual subjects were characterised by increased maternal dominance, emotional abuse and neglect compared to controls, with males being exposed to a disengaged maternal style and more paternal emotional neglect and criticism. Both MF and FM transsexuals were made felt that in areas of achievement they will inevitably fail. There is no evidence of elevated levels of psychiatric symptoms in GID, but potential predisposing factors, particularly in MF transsexuals, are present; these may originate from the more intense rejection they experience.

Mental health and gender dysphoria: A review of the literature

Abstract

No full-text available

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