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Female-to-male transgender quality of life

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  • Toronto Metropolitan University

Abstract and Figures

We evaluated health-related quality of life in female-to-male (FTM) transgender individuals, using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Using email, Internet bulletin boards, and postcards, we recruited individuals to an Internet site (http://www.transurvey.org), which contained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM transsexual participants, of which 384 were from the US. Analysis of quality of life health concepts demonstrated statistically significant (p<0.01) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (p<0.01) than those who had not received hormone therapy. FTM transgender participants reported significantly reduced mental health-related quality of life and require additional focus to determine the cause of this distress. Providing this community with the hormonal care they request is associated with improved quality of life.
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Female-to-male transgender quality of life
Emily Newfield
1,5
, Stacey Hart
2
, Suzanne Dibble
3
& Lori Kohler
4
1
School of Medicine, University of California, San Francisco, CA, USA;
2
Department of Psychiatry,
University of California, San Francisco, CA, USA;
3
Institute for Health and Aging, University of California,
San Francisco, CA, USA;
4
Department of Family and Community Medicine, University of California, San
Francisco, CA, USA;
5
School of Medicine, University of California, San Francisco, CA, USA (E-mail:
emily.newfield@gmail.com)
Accepted in revised form 30 March 2006
Abstract
Objectives: We evaluated health-related quality of life in female-to-male (FTM) transgender individuals,
using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Method s: Using email, Internet
bulletin boards, and postcards, we recruited individuals to an Internet site (http://www.transurvey.org),
which con tained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM
transsexual participants, of which 384 were from the US. Result s: Analysis of quality of life health concepts
demonstrated statistically significant (p<0.01) diminished quality of life among the FTM transgender
participants as compared to the US male and female population, particularly in regard to mental health.
FTM transgender participants who received testosterone (67%) reported statistically significant higher
quality of life scores (p<0.01) than those who had not received hormone therapy. Conclusions: FTM
transgender participants reported significantly reduced mental health-related quality of life and require
additional focus to determine the cause of this distress. Pro viding this community with the hormonal care
they request is associated with improved quality of life.
Key words: Female, Female-to-male transgender, Gender identity, Internet, Male, Quality of life, Trans-
gender, Transsexualism/psych ology
Abbreviations: FTM Female-to-male (FTM) transgender participants were labeled female at birth and
choose to identify as male; HBIGDA The Harry Benjamin International Gender Dysphoria Association
(HBIGDA) is a US-based professional association for individuals that provide services to the transgender
community; QOL Health-related quality of life (QOL) is a way of defining the level of functioning and
perceived well-being in an individual; SF36v2 The Short Form 36-Item Questionnaire version 2 (SF36v2)
is a health-related quality of life measurement tool containing 36 questions, that cover 8 domains of
physical and mental health
Background
Transgender is an umbrella term used to incor-
porate people of various gender identifications,
including transsexuals, drag queens and drag
kings, masculine women, feminine men, and others
who violate normative gender laws but who do not
necessarily seek and/or obtain surgical and medi-
cal treatment. Transsexual is typically used to
describe individuals who use both hormonal
and surgical therapy to augment their bodies. A
female-to-male transgender person (FTM) was
Quality of Life Research (2006) 15:1447–1457 Springer 2006
DOI 10.1007/s11136-006-0002-3
labeled female at birth, and chooses to identify as
male, whether or not he receives transgender
medical treatment.
The present study focuses on FTM transgender
health for several reasons. First, the literature is
deficient in its ability to describe the positive and
negative effects of transgender medical treat ment,
including the long-term effects of hormone use and
sex-reassignment surgery. Second, active discrimi-
nation by health care providers creates an enor-
mous barrier to prompt treatment of medical
concerns [1, 2]. In addition, many health care
professionals lack appropriate training regardi ng
treatment protocols and health issues for trans-
gender patients. Finally, transgender people are
often isolated and marginalized within the com-
munity at large, known risk factors for poor health
status [3, 4].
The Harry Benjamin Intern ational Gender
Dysphoria Association (HBIGDA) is a US-based
professional association for individuals who pro-
vide services to the transgender community. The
organization creates transgender treatment proto-
cols, and the HBIGDA Standards of Care state
that the goal of transgender medical treatment is
‘‘lasting personal comfort with the gen dered self in
order to maximize overall psychological well-being
and self-fulfillment’’ [5], which can be interpreted
as improved quality of life. Quality of life (QOL) is
a way of defining the level of functioning and
perceived well-being in a patient population.
Sex reassignment therapy is an important aspect
of transgender medical treatment and improved
QOL following therapy has been demonstrated in a
few small studies from Yugoslavia [6], Germany [7],
and Sweden [8]. All of these works examined QOL
in both female-to-m ale and male-to-female trans-
gender people, and QOL was defined inconsistently
and narrowly, including improved intimate rela-
tionships and work opportunities [6], limited med-
ical complications and treatment side effects [7],
and impr oved psychiatric functioning [8]. These
results have limited application to a US population
of transgender individuals because of the vast dif-
ferences in care between European and American
transgender people. In European countries that
offer transgender treat ment systems (including
Holland, Sweden, and Belgium), patients are re-
cruited into a single clinic, given state-funded,
predictable care, and followed over time by a con-
sistent team of physicians and counselors. Most
American transgender people receive health care in
a rather unsystematic fashion and are fortunate to
find a sensitive, non-discriminatory primary care
physician who is familiar with a transgender
treatment protocol. US privat e health insurance
typically does not cover the costs of hormone or
surgical treatment because the treatment is con-
sidered cosmetic, and therefore, unnecessary. Some
state-based public health systems, such as Califor-
niaÕs Medi-Cal insurance program, wi ll pay for
hormone and surgical therapy for indigent trans-
gender people but review requests for care on a
case-by-case basis and often den y them.
Although many European transgender patients
can depend on a dedicated medic al team focused
exclusively on their care, qualitative research has
affirmed that US transgender people routinely
experience discriminatory practices and provider
insensitivity when accessing health care services [9,
10]. Because American transgender patients can-
not rely on a supportive health care system, their
QOL may suffer substantially. Therefore, an
important aspect of this study is an examinati on of
the association between QOL and the receipt of
sex reassignment therapies in American FTMs.
Objectives
To examine QOL in the female-to-male transgen-
der community, we used the Short Form 36-It em
Questionnaire version 2 (SF36v2) [11] via the
Internet to evaluate eight domains of health-re-
lated quality of life. The SF36v2 is a generic, valid,
accessible, and clinically relev ant tool for assessing
QOL in a population. The Internet is an excellent
tool for transgender health research because
the transgender community relies heavily on the
Internet for information gathering and social net-
working [12]. In addition, the appropriateness of
using the SF36v2 as an Internet-based tool has
been tested [13].
The current study had two objectives. The first
objective was to examine QOL in FTM transgen-
der people, and the empirical question of whet her
FTM QOL (as related by the SF36v2 health con-
cepts) differs from the general US population of
men and women. One might expect FTMs to
report lower levels of QOL than the general
1448
population, because of social discrimination and
stigmatization, as seen in other US communities
that experience prejudice [14]. Alternatively, we do
not believe FTM transgender identity to be indic-
ative of psychopathology or a disease state. This
presumption is supported by data from European
population-based studies of the FTM transgender
community, which demonstrate no statistically
significant increases in mortality or morbidity
when compared against the female population as a
whole [15].
The second objective was to examine differences
in QOL within groups in the FTM population. We
expected FTMs who are in the first 2 years of sex
reassignment treatment to report lower health-re-
lated QOL compared with those who are further
along in the gender transition process. We based
this hypothesis on the understanding that gender
transformation can be a difficult process, some-
times involving complicated and debilitat ing sur-
geries, and that transgender individuals experience
decreased social and fami lial acceptance and sup-
port [10, 16].
Methods
Participants and procedures
To enroll in the study, FTM transgender individ-
uals were directed to the secure website http://
www.transurvey.org. We con ducted recruitment
via online promotion and print ed materials,
including flyers and postcards that were distributed
to San Francisco Bay Area community centers,
cafes, stores, and health clinics that serve the
transgender community. We encouraged partici-
pation by individuals who currently identify as fe-
male-to-male transgender or transsexual, or have
identified as FTM in the past and now identify as
male. We required a unique user name and pass-
word to advance beyond the home page of the
website. Although this procedure helped prevent
duplicate submissions by the same participant, we
could not employ more sophisticated computerized
systems due to administrative and financial con-
straints. We ensured voluntary enrollment in this
study by using an Informed Consent web page, that
contained the University of California at Berkeley
Committee for the Protection of Human Subjects
and University of California at San Francisco
Committee on Human Research approved text.
Users who did not click the ‘‘I Consent’’ button
could not advance to the remainder of the study.
Participants who completed both the requirements
for user identification and informed consent were
allowed access to the Demographics and Health
Survey porti ons of the study. Our web version of
the SF36v2 closely approximates the design of the
paper version and we did not modify the questio ns
from their published wording and format. After
submitting their SF36v2 responses, users were of-
fered a real-time report of their SF36v2 responses,
along with comparison data for men and women in
the participantÕs age category. Quality Metric
Incorporated, the creators and managers of the
SF36v2, provided the comparison data. All par-
ticipants received a discount coupon redeemable at
an Internet store.
Measures
The Demographics section assessed subject infor-
mation about age, education, race, income, gender
identity, country of origin, locale, testosterone use,
receipt of surgery, insurance status, and experience
of health care discrimination. Health-related QOL
was determined using the Short-Form 36 Version 2
[11]. The SF36v2 measures health using questions
to assess eight domains. Table 1 explains each of
these domains with an associated sample question
from the survey.
The SF36v2 reli es on a norm-based scoring
method, incorporating general United States
population health norms (obtained from the 1998
National Survey of Functional Health Status) into
the scoring so that all SF36v2 domains have a
mean of 50 and standard deviation of 10 [17].
Norm-based scoring enables easier interpretation
of changes in QOL, as all scores above or below 50
are equivalent to above or below the population
norm.
Statistical analyses
We downloaded data as a text file from the secure
website and imported the data into SPSS 12.0 for
Windows (SPSS Inc, Chicago, IL) and Intercooled
Stata 7 (Statacorp LP, College Station, TX) for
analyses. We used independent samples T-tests
and one-way ANOVAs to determine significant
1449
QOL differences in the study sample. Because our
analyses were largely exploratory, statistical sig-
nificance was set at a=0.01, instead of the usual
a=0.05. Furthermore, because we conducted
multiple statistical tests in the age-based analyses,
we used the Bonferroni correction procedure to
adjust the a level downwards (a=0.00125) and
correct for an increased chance of Type I error.
Results
Participant characteristics
Between October 2003 and October 2004, 446
individuals completed the survey hosted on the
study website. Table 2 presents the characteristics
of all participants. The average participant was in
his thirties, identified as white, lived in an urban
area, and had health insura nce. Because ‘‘Date of
Birth’’ was the only required field for advancement
to the QOL survey, not all participants answered
every question of the demographic survey.
Quality of life outcomes
Overall norms
Given that the comparison health norms are from
a US sample, we chose to analyze health-related
QOL for the US members of our study sample
only (n = 384). Of the 384 US subjects, we
excluded four individuals who identified as
‘‘female’’ and one subject who did not submit
gender identity information. Additionally, three
subjects submitted incomplete quality of life sur-
veys and we could not evaluate their responses for
all quality of life domains (Table 3). Therefore,
our final sample for quality of life data analysis
was n = 376. For all health domains except Role
Physical and Bodily Pain, the transgender group
differs significantly from the general population.
For the mental health concepts (Vitality, Role
Emotional, Mental Health, and Mental Health
Summary Score) and for Social Functioning
(which reflects physical and/or emotional impact
on social activities) FTMs in our sampl e reported
lower QOL than the general population, reflecting
diminished mental-health related QOL. For the
Physical Functioning concept and the Physical
Health Summary Score, FTMs in our sample re-
ported significantly higher scores than the general
US population.
Age-specific QOL norms
To investigate the effect of age on QOL scores, we
compared our FTM transgender sample to males
and females in specific age groups, using norms for
Table 1. SF-36v2 domains and sample questions
Domain Sample question
Physical Functioning: evaluates aspects of physical limitations,
both minor and severe
Does your health now limit you in vigorous activities, such as
running, lifting heavy objects, participating in strenuous sports?
Role Physical: assesses limitations in work or activities due to
physical health problems
During the past 4 weeks, how much of the time have had any of
the following problems with your work or other regular daily
activities as a result of your physical health?
Bodily Pain: measures intensity and impact of pain How much bodily pain have you had during the past 4 weeks?
How much did pain interfere with your normal work (including
both work outside the home and housework)?
General Health: assesses individualÕs perception of well-being In general would you say your health is excellent, very good,
good, fair, or poor?
Vitality: measures energy and fatigue, as well as impact of
disease or treatment on health
How much of the time in the past 4 weeks did you feel full of life?
Social Functioning: measures impact of health on social
activities
During the past 4 weeks, to what extent has your physical
health or emotional problems interfered with your normal
social activities with family, friends, neighbors, or groups?
Role Emotional: to assess limitations in work or activities due
to mental health problems
During the past 4 weeks, how much of the time have had any of
the following problems with your work or other regular daily
activities as a result of any emotional problems (such as feeling
depressed or anxious)?
Mental Health: assesses overall mental health How much of the time in the past four weeks have you been
very nervous?
1450
subgroups of the US general population (Tables 4
and 5). As a whole, FTM health-related QOL
scores showed fewer statistically significant differ-
ences from US female scores than from US male
scores. FTM transgender people age 44 and
younger scored significantly low er than US males
and females in the Social Functioning, Role
Emotional, Mental Health, and Mental Health
Summary Score domains, which are designed to be
the dominant mental health dom ains in the survey.
Although FTMs reported significantly lower
scores in the General Health and Vital ity domains
when compared to males in their age group, no
statistically significant differences were found
between FTMs and females in any age group for
the physical health QOL domains.
Hormone therapy
We evaluated subgroups of our FTM transgender
sample with the goal of determining whether
hormone therapy influences QO L. Those who
had received testosterone at any time reported
higher health-related QOL scores than those who
had not, with statistically significant differences
Table 2. FTM transgender study participant characteristics at enrollment
Country of origin (n = 444) n (%)
United States 384 (86.5)
Canada 40 (9.0)
European Union 11 (2.5)
Other 9 (2.0)
Gender identity (n = 443) n (%)
Female-to-male transsexual 180 (40.6)
Female-to-male transgender 178 (40.2)
Male 80 (18.1)
Female 5 (1.1)
All participants (n = 446) US participants,
FTM or male identified only (n = 379)
Age, mean (SD) 32.8 (11.2) 32.6 (10.8)
Area of residence, n (%)
Urban 352 (79.6) 298 (78)
Rural 90 (20.4) 84 (22)
Testosterone usage, n (%)
Ever 301 (68.1) 254 (67)
Current 286 (64.7) 242 (64)
Surgical procedures, n (%)
Top surgery 164 (37) 139 (37)
Bottom surgery 12 (3) 11 (3)
Health insurance, n (%)
Yes 326 (74.8) 282 (74)
No 100 (22.9) 82 (22)
DonÕt know 10 (2.3) 8 (2)
Race, n (%)
White 358 (90.4) 299 (89)
Latino 13 (3.3) 12 (3.6)
African–American 6 (1.5) 6 (1.8)
Asian 6 (1.5) 6 (1.8)
Other 13 (3.3) 13 (3.8)
Education, n (%)
High school 386 (88) 331 (88)
<High school 54 (12) 45 (12)
Annual household income, n (%)
£ $19,999 173 (40.0) 146 (39.5)
>$20,000 259 (60.0) 224 (60.5)
Health care discrimination, n (%)
Experienced discrimination from provider 74 (16.7) 64 (16.8)
Delayed seeking care due to fear of discrimination 312 (70.7) 273 (72.4)
1451
(p<0.01) in the Vitality, Social Funct ioning, Role
Emotional, and Mental Health domains. When we
controlled for the possible influence of income and
education on quality of life, we fou nd that tes-
tosterone usage independently predicts higher
quality of life scores (p<0.01) in the Social
Functioning, Mental Health, and Mental Health
Summary domains, with marginal statistical sig-
nificance (p<0.05) in the Vitality and Role Emo-
tional domains (Table 6).
Most FTM study participants who had used
testosterone at any time reported taking testos-
terone for less than 5 years (n = 203). The over-
whelming majority of these subjects (76%) were
40-years-old or younger. When we examined QOL
differences between testosterone users based on
their length of treatment, the only statistically
significant differences we found were in the Phys-
ical Functioning and Physical Health Summary
Score for individuals who had used testosterone
for more than 15 years. These individuals also
were more likely to be 50-years-old or older. When
the treatment length categories were collapsed
into £ 1 year and >1 year, individuals with
>1 year of treatment reported statistically signif-
icant higher scores only in Role Emotional domain
(p=0.047).
Surgical treatment
We focused our surgical treatment analysis on
those who reported having undergone ‘‘top’’ sur-
gery (mastectomy or chest reconstruction). Chest
reconstruction not only enhances the FTM trans-
gender identity, increases self-esteem, and improves
body image, but provides some security and safety
for those who remove their shirts in public areas,
such as gyms or beaches. Those who had received
top surgery reported higher QOL scores than those
who had not received surgery, with statistically
significant findings (p<0.01) for the General
Health, Social Functioning, and all three mental
health concepts. Univariate analyses controlling
for possible influence of income and education on
quality of life revealed top surgery to be an inde-
pendent predictor of quality of life only in the
General Health domain (Table 7). W hen we ana-
lyzed QOL based on the length of time since sur-
gery, we found no statistically significant
differences across time. Most participants (50%)
reported receiving top surgery in the past year, and
84% had received surgery in the past 4 years. When
the surgical time variable was collapsed into those
who had surgery 1 year ago or less and those who
had surgery more than 1 year ago, no statistically
significant differences in QOL were observed.
Discussion
The 376 US FTM transgender participants ana-
lyzed in this sample had diminished mental-health
related QOL compared with the general US pop-
ulation, as measured by the SF36v2. These find-
ings are consistent when compared against specific
age and sex norms. This study did not reveal
whether the mental health distress reported by this
sample of FTMs is generated by internal conflict
regarding gender identity, as suggested by the
Table 3. Health-related quality of life in a US female-to-male transgender sample (n = 376)
Health concepts Mean (SD)
a
Test statistic
b
p Value
b
General Health 47.76 (10.5) )4.2259 <0.001
Physical Functioning 51.79 (7.6) 3.4299 <0.001
Role Physical 50.59 (8.8) 1.124 0.261
Bodily Pain 49.73 (9.9) )0.5117 0.608
Vitality 46.22 (9.9) )7.1617 <0.001
Social Functioning 43.14 (10.9) )12.928 <0.001
Role Emotional 42.42 (11.6) )14.192 <0.001
Mental Health 42.12 (10.2) )14.907 <0.001
Physical Summary Score 53.45 (9.42) 6.700 <0.001
Mental Summary Score 39.63 (12.2) )19.317 <0.001
a
SD = standard deviation.
b
Based on independent samples T-test, comparing the FTM sample to the US general population norms. The mean and standard
deviation for the comparison sample are 50 and 10, respectively, for all health concepts.
1452
DSM-IV and members of the psychiatric com-
munity, or is the result of discrimination and social
alienation. Regardless of the root cause of the
mental health distress, FTM transgender people
would benefit from greater access to the full
spectrum of health services to help alleviate their
distress.
Overall, in our FTM transgender sample phys-
ical well-being does not appear to be diminished.
When compared with men in their same age cate-
gory, FTMs in this sample appear to have dimin-
ished physical health. This decreased physical
health is not seen when they are compared with
women in their age category. Because FTM people
are biologically female, they may be more physi-
cally similar to women than to men.
Our second objective was to examine whether
individuals in the first few years of gender transi-
tion report diminished QOL. We found no signif-
icant relationship between treatment length and
QOL, although in this sample receiving hormone
therapy was significantly associated with increased
well-being, independent of socioeconom ic status.
This point is important because many health
insurance plans refuse to pay for transgender-
specific treatment without considering the impact
on QOL. FTM transgender people are requesting
services that are not incidental, cosmetic remedies,
but rather therapies key to their well-being.
Unfortunately, this work does not determine
whether FTMs who seek and obtain medical ser-
vices directly related to their transgender identity
experience are psychologically healthier at baseline
than FTMs who do not, or cannot, seek the same
care.
Study strengths
For the first time, a large sample of data regarding
the FTM transgender community is available for
analysis. These data reveal issues and concerns
specific to the FTM transgender community and
highlight the particular struggles of the commu-
nity. For example, although our study participants
are highly educated (48% having received a
bachelorÕs degree or higher), the majority earn less
than the US national average.
By using the Internet as a survey tool, we have
gathered information about FTMs from 40 states
Table 4. FTM transgender health-related quality of life compared with US population norms for males
Health concept Ages 18–24 Ages 25–34 Ages 35–44 Ages 45–54
FTM
(N = 111)
National norm
(N = 50)
FTM
(N = 133)
National norm
(N = 419)
FTM
(N = 86)
National norm
(N = 700)
FTM
(N = 34)
National norm
(N = 543)
General Health 46.88 (9.99) 52.02 (8.22) 48.04 (10.69) 52.5 (8.46) 48.73 (10.47) 51.75 (9.21) 47.39 (12.08) 50.27 (9.99)
Physical Functioning 53.52 (5.45) 54.26 (7.22) 52.89 (6.31) 54.56 (6.16) 50.83 (8.92) 53.48 (6.45) 49.41 (9.61) 51.38 (8.6)
Role Physical 51.17 (8.19) 54.5 (6.3) 51.6 (7.26) 53.64 (6.96) 50.29 (9.895) 52.86 (7.85) 47.41 (11.00) 51.06 (9.45)
Bodily Pain 50.05 (8.82) 51.71 (8.42) 51.47 (8.63) 53.18 (8.7) 49.09 (11.26) 51.49 (8.92) 45.42 (10.27) 50.39 (9.69)
Vitality 45.25 (9.98) 49.86 (9.65) 46.52 (8.91) 51.58 (8.51) 46.91 (10.45) 51.41 (9.5) 46.58 (12.84) 51.63 (10.14)
Social Functioning 42.69 (10.64) 50.84 (7.0) 42.70 (10.66) 52.46 (7.43) 44.74 (10.66) 51.41 (8.78) 42.57 (13.29) 50.43 (10.25)
Role Emotional 40.18 (11.52) 52.69 (5.93) 41.73 (10.91) 52.79 (7.0) 45.55 (11.94) 51.9 (8.14) 43.87 (12.67) 51.06 (9.42)
Mental Health 40.46 (10.14) 49.76 (8.33) 43.21 (9.01) 51.28 (8.35) 42.29 (10.43) 50.36 (9.67) 42.88 (13.62) 50.79 (10.12)
Physical Health Summary Score 55.07 (7.84) 53.96 (7) 54.86 (7.74) 54.05 (6.63) 52.27 (11.01) 52.98 (7.6) 49.44 (10.80) 50.81 (9.37)
Mental Health Summary Score 37.05 (12.22) 49.51 (7.14) 39.34 (11.11) 51.02 (7.64) 41.99 (11.93) 50.39 (9.56) 42.02 (15.40) 50.85 (10.05)
Total number of individuals analyzed = 364 (12 US FTM participants submitted incomplete demographics and/or quality of life surveys).
Data presented as quality of life score mean (standard deviation).
Numbers in bold represent statistically significant differences in mean scores (p<0.00125), based on independent sample T-tests.
1453
which makes this one of the broadest samples of
FTMs ever recruited. The finding that 20% of
transurvey respondent s live in rural settings pro-
vides evidence that transgender pe ople inhabit
many different communities in the United States,
not just the urban environments that are assumed
to be more hospitable to gender variant individu-
als.
This project recruited all individuals who pres-
ently identify as FTM transgender or transsexual,
and specifically en couraged enrollment among
individuals who currently identify as male, but
who have identified as transgender in the past.
Nearly 20% of our enrolled participants currently
identify as male, but most continue to take hor-
mone therapy to support their bodily transfor-
mation. This finding demonstrates that a
significant number of an FTM transgender target
sample may be difficult to locate if research focuses
solely on those who identify currently as trans-
gender and fails to include those who have a
transgender history.
The greatest strength of this project is its ability
to clarify some of the health needs and issues for
FTM transgen der people. This information can be
used to educate the health care and transgender
communities, as well as to support future funding
applications for more comprehensive projects
around transgender health.
Study limitations
This survey, as with all research pertaining to the
transgender community, is biased by self-selection.
To be transgender is to identify as such there is
no particular physical finding or diagnostic test
that can certify that an individual is truly the
gender he or she reports to be. Therefore, we
consider all individuals who believe they meet
inclusion criteria as valid participants in this study.
Clearly, there is a significant opportunity for
individuals to falsify their identi ty in order to
participate. Our approach is to trust that those
who participate are doing so because of their de-
sire to contribute to the body of transgender-fo-
cused research.
This project is limited by its mode of recruit-
ment. Those who can success fully navigate the
Internet for information gathering (such as email
Table 5. FTM transgender health-related quality of life compared with US population norms for females
Health concept Ages 18–24 Ages 25–34 Ages 35–44 Ages 45–54
FTM
(N = 111)
National norm
(N = 157)
FTM
(N = 133)
National norm
(N = 619)
FTM
(N = 86)
National norm
(N = 820)
FTM
(N = 34)
National norm
(N = 873)
General Health 46.88 (9.99) 48.14 (9.55) 48.04 (10.69) 50.86 (9.61) 48.73 (10.47) 50.15 (9.8) 47.39 (12.08) 49.23 (10.66)
Physical Functioning 53.52 (5.45) 53.04 (6.56) 52.89 (6.31) 52.96 (7.16) 50.83 (8.92) 51.4 (8.59) 49.41 (9.61) 48.63 (10.06)
Role Physical 51.17 (8.19) 51.66 (7.98) 51.6 (7.26) 51.73 (8.76) 50.29 (9.895) 51.35 (8.75) 47.41 (11.00) 49.56 (10.18)
Bodily Pain 50.05 (8.82) 51.89 (8.43) 51.47 (8.63) 51.44 (9.64) 49.09 (11.26) 49.95 (9.64) 45.42 (10.27) 48.07 (10.29)
Vitality 45.25 (9.98) 45.65 (8.82) 46.52 (8.91) 48.08 (10.11) 46.91 (10.45) 48.36 (9.92) 46.58 (12.84) 49.37 (9.98)
Social Functioning 42.69 (10.64) 48.26 (10.72) 42.70 (10.66) 49.43 (9.94) 44.74 (10.66) 49.3 (10.14) 42.57 (13.29) 49.69 (10.12)
Role Emotional 40.18 (11.52) 48.26 (10.92) 41.73 (10.91) 49.71 (9.64) 45.55 (11.94) 49.91 (9.62) 43.87 (12.67) 50.22 (9.9)
Mental Health 40.46 (10.14) 45.34 (10.74) 43.21 (9.01) 47.78 (10.6) 42.29 (10.43) 47.74 (10.45) 42.88 (13.62) 49.6 (9.96)
Physical Health Summary Score 55.07 (7.84) 53.26 (7.18) 54.86 (7.74) 53.03 (7.91) 52.27 (11.01) 51.56 (8.62) 49.44 (10.80) 48.49 (10.47)
Mental Health Summary Score 37.05 (12.22) 44.43 (11.41) 39.34 (11.11) 47.14 (10.74) 41.99 (11.93) 47.80 (10.35) 42.02 (15.40) 50.24 (9.84)
Total number of individuals analyzed = 364 (12 US FTM participants submitted incomplete demographics and/or quality of life surveys).
Data presented as quality of life score mean (standard deviation).
Numbers in bold represent statistically significant differences in mean scores (p<0.00125), based on independent sample T-tests.
1454
lists and web-based organizations) automatically
have a certain degree of literacy and technological
sophistication. Internet access requires a com-
puter, which for many is still a luxury item. This
limitation may be the source of our racially-biased
sample; more individuals report living in Canada
than identify as African–American. Unfortu-
nately, there are no comparable FTM transgender
population data in the research literature to help
us evaluate the impact of recruitment bias on our
study sample.
The issues of potential bias are significant and,
as such, the results reported here may not reflect
the health and well-being of the entire FTM
transgender community, but only the experiences
of white, educated, urban FTMs. Given that
American non-whites report mental health distress
more frequently than whites, regardless of socio-
economic status [18], it is possible that FTMs of
color, who are not well-represented in this study,
may report even lower mental health-related
quality of life than white FTMs.
Another significant limitation of this project is
the use of the SF36v2 as our QOL measurement
tool. Although we appreciate the SF36v2 for its
generic language, its self-administering capacity,
its validity, and its proven use as a web-based
instrument, we recognize that it is not a diagnostic
tool. Even though low scores on the SF36v2
mental health domains are correlated with poor
mental health outcomes (i.e., in-patient mental
health care, suicidal ideation, clinical depression)
[11], this study does not help us understand specific
mental disorders that may be present in the
Table 7. Health-related quality of life in a US female-to-male transgender sample, according to top surgery
Health concepts Ever received
top surgery (n = 136)
a
No top surgery
(n = 230)
a
F statistic p Value
b
General Health 50.10 (9.6) 46.07 (10.8) 7.633 0.006
Physical Functioning 52.74 (7.1) 51.47 (7.8) 0.509 0.476
Role Physical 51.15 (9.2) 50.09 (8.7) 0.004 0.948
Bodily Pain 50.61 (10.1) 49.08 (9.8) 0.004 0.951
Vitality 48.41 (9.4) 44.81 (10.2) 4.596 0.033
Social Functioning 45.05 (10.6) 41.85 (11.0) 1.633 0.202
Role Emotional 44.32 (11.4) 41.30 (11.7) 1.105 0.294
Mental Health 44.25 (9.2) 40.73 (10.7) 3.575 0.059
Physical Summary Score 54.13 (9.4) 52.98 (9.5) 0.185 0.667
Mental Summary Score 42.21 (11.6) 38.01 (12.5) 3.364 0.067
Surgery information and quality of life scores available for 366 US FTM or male identified study participants.
a
Mean quality of life score (standard deviation).
b
Based on univariate analysis of variance, controlling for income and education.
Table 6. Health-related quality of life in a US female-to-male transgender sample, according to testosterone therapy
Health concepts Ever received
testosterone (n = 248)
a
No testosterone
usage (n = 117)
a
F statistic p Value
b
General Health 48.34 (10.3) 45.92 (11.1) 2.399 0.122
Physical Functioning 52.34 (7.4) 51.10 (7.8) 0.805 0.370
Role Physical 50.38 (9.3) 50.69 (7.9) 0.761 0.384
Bodily Pain 49.70 (10.1) 49.54 (9.7) 0.689 0.407
Vitality 47.11 (9.7) 44.11 (10.5) 4.679 0.031
Social Functioning 44.34 (10.3) 40.30 (11.8) 8.063 0.005
Role Emotional 43.69 (11.5) 39.76 (11.6) 6.340 0.012
Mental Health 43.23 (9.8) 39.52 (10.9) 7.042 0.008
Physical Summary Score 53.29 (9.6) 53.67 (9.2) 0.887 0.347
Mental Summary Score 41.22 (11.9) 36.08 (12.6) 10.986 0.001
Hormone usage and quality of life scores available for 365 US FTM or male identified study participants.
a
Mean quality of life score (standard deviation).
b
Based on univariate analysis of variance, controlling for income and education.
1455
community. Our significant findings in the mental
health domains demand that the FTM co mmunity
be screened with psychological indices and scales
to identify the particular mental health problems
within the community.
Future research
If the research goal is to evaluate QOL in a
transgender population, an ideal project would
recruit individuals when they first contact a health
care provider and follow those individuals forward
through their transition. Health-related QOL
assessment at different stages of the transition
period, in conjunction with detailed interviews,
would help evaluate the relationship between
gender identity and the physical and psychological
changes that accompany the transition. Of course,
this approach limits enrollment to those FTMs
who have access to a physician, and excludes those
who identify as transgender but who do not seek
medical treatment.
We know from our analyses that those who
receive hormone treatment report better QOL
than those who have not, but we do not know the
number of FTMs who desire care and have not
been able to obtain it, or those who anticipate
receiving care in the future. We also do not have
information regarding the quality of intimate
relationships and whether those relationships have
experienced turmoil during their transgender
transition period. A more complete understanding
of this community would include a qualitative
investigation of QOL.
Detailed interviews are essential for the genera-
tion of research tools specific to the FTM trans-
gender community. Future projects should begin
by organizing focus groups of FTMs of different
ages and identities with the goal of critiquing and
altering demographic surveys and QOL tools. This
approach would not only create a community
investment in the project, but also would generate
results that more accurately reflect the FTM
experience.
Conclusions
This projectÕs success provides us with information
about the FTM transgender community that was
previously unavailable and demonstrates the fea-
sibility of Internet-based health research. By
highlighting the particular health needs of FTM
people, we can advocate for enhanced services,
targeted programs, and future research projects.
Participants routinely expressed gratitude and
enthusiasm for this survey, which informs us that
the transgender community desires the concerned
focus of the medical community and is willing to
participate in future projects. The need for infor-
mation and for improved relationships with the
medical community is great.
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Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients' own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.
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Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.
Article
The optimum steroid hormone treatment regimes for transsexual subjects has not yet been established. We have investigated the mortality and morbidity figures in a large group of transsexual subjects receiving cross-sex hormone treatment. A retrospective, descriptive study in a university teaching hospital. Eight hundred and sixteen male-to-female (M-->F) and 293 female-to-male (F-->M) transsexuals. Subjects had been treated with cross-sex hormones for a total of 10,152 patient-years. Standardized mortality and incidence ratios were calculated from the general Dutch population (age- and gender-adjusted) and were also compared to side effects of cross-sex hormones in transsexuals reported in the literature. In both the M-->F and F-->M transsexuals, total mortality was not higher than in the general population and, largely, the observed mortality could not be related to hormone treatment. Venous thromboembolism was the major complication in M-->F transsexuals treated with oral oestrogens and anti-androgens, but fewer cases were observed since the introduction of transdermal oestradiol in the treatment of transsexuals over 40 years of age. No cases of breast carcinoma but one case of prostatic carcinoma were encountered in our population. No serious morbidity was observed which could be related to androgen treatment in the F-->M transsexuals. Mortality in male-to-female and female-to-male transsexuals is not increased during cross-sex hormone treatment. Transdermal oestradiol administration is recommended in male-to-female transsexuals, particularly in the population over 40 years in whom a high incidence of venous thromboembolism was observed with oral oestrogens. It seems that in view of the deep psychological needs of transsexuals to undergo sex reassignment, our treatment schedule of cross-sex hormone administration is acceptably safe.