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Abstract
Despite being recognized as an important prognostic factor for the outcome in gender identity disorder (GID), psychiatric comorbidity has rarely been assessed by means of standardized diagnostic instruments. The aim of this study was to assess current and lifetime psychiatric comorbidity in patients with GID.
A cross-sectional sample of 31 patients who were treated for GID was assessed by the structured clinical interview for Axis I and II (SCID-I/II) and the Hospital Anxiety and Depression Scale (HADS).
Twenty-nine percent of the patients had no current or lifetime Axis I disorder; 39% fulfilled the criteria for current and 71% for current and/or lifetime Axis I diagnosis. Forty-two percent of the patients were diagnosed with one or more personality disorders.
Lifetime psychiatric comorbidity in GID patients is high, and this should be taken into account in the assessment and treatment planning of GID patients.
... Kullgren, Sundbom, & Hojerback, 1993;De Cuypere, Janes, & Rubens, 1995;Hepp, Klaghofer, Burkhard-Kübler, & Buddeberg, 2002;Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005;Hoshiai et al., 2010;Lobato et al., 2006;Mate-Kole, Freschi, & Robin, 1988;Miach et al., 2000;Pfäfflin & Junge, 1990). Die methodische Qualität der Studien entspricht dem Evidenzgrad III, die Ergebnisse schwanken: So gibt es Studien, bei denen psychische Störungen in der klinischen Stichprobe ebenso häufig sind wie in der Allgemeinbevölkerung (Cole et al., 1997). ...
... Weitere Arbeiten erfassen ca. 70 % Achse I-Störungen (Hepp et al., 2005;Heylens, Elaut, et al., 2014), wobei sich die Angaben zu Achse II-Störungen unterscheiden (Hepp et al., 2005: 42 %;Heylens, Elaut, et al., 2014: 15 %). In der Fallserie von Levine und Solomon (2009) findet sich bei neun von zehn Patienten Psychopathologie. ...
... versäumter Therapie wird diskutiert (vgl. . Depression und Angststörungen sind am häufigsten (Hepp et al., 2005;Lobato et al., 2006), sofern sie nicht a priori zu Anpassungsstörungen deklariert werden (Gomez-Gil, Trilla, et al., 2009;Hoshiai et al., 2010). Angaben zu Suizidgedanken und Suizidversuchen gibt es in der Kohortenstudie von Pitts et al. (2009), der Fall-Kontroll-Studie von (Mathy, 2002), einer Querschnittsstudie (Nemoto, Bodeker, & Iwamoto, 2011) sowie bei fünf weiteren Arbeiten (Dhejne et al., 2011;Haas et al., 2011;Liu & Mustanski, 2012;Terada et al., 2011). ...
IntroductionThis paper introduces the German S3-guideline Gender Incongruence, Gender Dysphoria and Trans Health: Diagnostics, Counselling and Treatment that was finalized in October 2018.Objectives
The objective of the guideline group was to adapt the 1997 Standards for Treatment and Expert Opinion on Transsexuals to current scientific developments and research results and to make them applicable for appropriate health care in Germany.Methods
The treatment recommendations of the guideline are based on empirical evidence which was systematically researched and evaluated. In a structured consensus process, the guideline group, who is representative for the target group, and a stakeholder group of trans people in Germany agreed on 100 recommendations.ResultsThe guideline aims to individualize and deregulate the field of trans health care. Reasonable options for the treatment of gender incongruence and/or gender dysphoria are identified. Based on empirical and clinical evidence, a procedure is recommended which is tailored to the individual conditions of the treatment.Conclusion
The guideline reflects the current international state of trans health care on the basis of empirical evidence and relates it to the German health care system. Its application should be backed up by clinical and therapeutic expertise.
... In the past decade, a small but growing body of literature has shed light upon the subject of psychiatric illness within the transgender community. The literature suggests an increase in the rates of mood, personality, and psychotic disorders, suicide, as well as various forms of substance abuse, including misuse of tobacco, alcohol and illicit substances [5][6][7][8][9][10][11] . These findings were corroborated by data derived from several surveys, the largest of which was the 2015 US Transgender Survey [5][6][7][8][9][10][11] . ...
... The literature suggests an increase in the rates of mood, personality, and psychotic disorders, suicide, as well as various forms of substance abuse, including misuse of tobacco, alcohol and illicit substances [5][6][7][8][9][10][11] . These findings were corroborated by data derived from several surveys, the largest of which was the 2015 US Transgender Survey [5][6][7][8][9][10][11] . In an effort to address the healthcare disparities and characterize the healthcare needs of this underserved population, the US Department of Health and Human Services Healthy People 2020 initiative and the National Institute of Medicine have called for prioritizing research on transgender and gender non-conforming patients using nationally representative data 2,12 . ...
... transgender youth or transwomen only). [5][6][7][8][9][10][11] The present study demonstrates a remarkably higher odds of psychiatric disorder diagnoses in transgender adult inpatient encounters than in cisgender inpatient encounters, elucidating the importance of mental health as a central component in the treatment approach of the transgender patient. In addition, it is the first study to delineate the divergent prevalence of medical comorbid diagnoses and differing demographic characteristics in the transgender populations with and without mental disorder diagnoses. ...
Purpose:
The purpose of the study was to determine the prevalence and odds of mental disorder diagnoses at discharge in U.S. transgender hospital encounters as compared with cisgender hospital encounters using nationally representative data.
Methods:
The National Inpatient Sample was used to identify 25,233 transgender and 254,437,363 cisgender inpatient encounters from 2007 to 2014. Univariate analyses were performed to compare the prevalence of mental disorders and comorbid medical diagnoses at the time of discharge. Multivariable analyses controlling for medical comorbid diagnoses were performed to assess the multivariable odds of mental disorder diagnoses in transgender versus cisgender hospital encounters. The prevalence of medical comorbid diagnoses in transgender encounters with and without mental disorder diagnoses was also compared.
Results:
The prevalence of mental disorder diagnoses was higher in transgender hospital encounters (77% vs. 37.8%, P < .001). The prevalence of each examined mental disorder diagnosis was significantly higher in transgender hospital encounters. A multivariable analysis demonstrated significantly higher odds of all mental disorder diagnoses (odds ratio [OR] = 7.94; confidence interval [CI], 7.63-8.26; P < .001), anxiety (OR = 3.44; CI, 3.32-3.56; P < .001), depression (OR = 1.63; CI, 1.57-1.70; P < .001), and psychosis (OR = 2.46; CI, 2.36-2.56; P < .001) among transgender versus cisgender inpatient encounters. Transgender encounters with a mental disorder diagnosis had a higher prevalence of chronic medical comorbid diagnoses as compared with transgender encounters without mental disorder diagnoses.
Conclusions:
Our findings suggest a high prevalence and significantly higher odds of mental disorder diagnoses in the transgender population as compared with the cisgender population using data that are nationally representative of the U.S.
Population:
... Las prevalencias de depresión a nivel internacional oscilan entre 33% y 66% (Hepp, Kraemer, Schnyder, Miller & Delsignore, 2005;Hoffman, 2014). No obstante, una de las principales preocupaciones acerca de la salud mental de las p e r s o n a s t r a n s e s e l r i e s g o d e s u i c i d i o (pensamientos suicidas e intentos de suicidio), así como las autolesiones (cortarse, golpearse o q u e m a r s e ) . ...
... En particular, los procedimientos médicos de afirmación de género han demostrado tener un impacto positivo en la salud mental y el bienestar psicológico de las personas trans (Tomita et al., 2018). Por ejemplo, investigaciones longitudinales muestran los efectos positivos de la terapia hormonal, logrando reducciones significativas de la psicopatología luego de 12 meses (Dhejne et al., 2016;Gómez-Gil et al., 2012;Hepp et al., 2005). ...
Las personas transgénero muestran prevalencias de problemas de salud mental significativamente muy superiores a las del resto de la población. Esto se debe, en gran parte, al estigma y la discriminación que padecen y al contexto de vulnerabilidad psicosocial en el que están insertas. El objetivo de este trabajo es presentar una sistematización y síntesis de los hallazgos científicos más recientes y relevantes acerca de la salud mental en personas transgénero, a nivel internacional y local. En primer lugar, se analizan los cambios ocurridos en las categorías diagnósticas en el sentido de la despatologización de las identidades trans. A continuación, se exponen las prevalencias más actuales acerca de problemas de salud mental en esta población, así como los principales factores de riesgo y protección que impactan en su desarrollo. Finalmente, se discuten las limitaciones más significativas de los estudios disponibles en salud mental en personas transgénero en el contexto regional y los vacíos existentes en el conocimiento en esta área, realizando recomendaciones para futuras líneas de investigación. Se espera que este trabajo contribuya a la actualización de los profesionales de la salud mental que asisten a población transgénero, desde una perspectiva científica, promoviendo una atención sanitaria libre de estigma y discriminación y reduciendo barreras al acceso de las personas transgénero a los servicios de salud.
... A pesar del creciente interés científico por las personas con disforia de género, sus hábitos de consumo o abuso de alcohol, tabaco y drogas ilícitas aún carecen de una investigación relevante. En estudios realizados en las unidades de género especializadas, los datos de prevalencia de abuso de alcohol y/o de drogas varían según el género y el país: de 11,3% a 50% en personas transexuales hombre-a-mujer (H-M) y de 3,8% a 61,5% en personas transexuales mujer-a-hombre (M-H) (Cole, O'Boyle, Emory y Meyer, 1997;De Cuypere, Janes y Rubens, 1995;Gómez-Gil, Trilla, Salamero, Godás y Valdés, 2009;Haraldsen y Dahl, 2000;Hepp, Kraemer, Schnyder, Miller y Delsignore, 2005;Landen, Walinder y Lundstrom, 1998;Verschoor y Poortinga, 1988). Mientras que en los Países Bajos (Verschoor y Poortinga, 1988), Suiza (Hepp et al., 2005) y los Estados Unidos (Cole et al., 1997) la prevalencia fue superior entre transexuales H-M que en M-H, en Bélgica (De Cuypere et al., 1995) y en Suecia (Landen et al., 1998) fue mayor en el subgrupo M-H; sin embargo, ninguna de estas diferencias resultaron estadísticamente significativas. ...
... En estudios realizados en las unidades de género especializadas, los datos de prevalencia de abuso de alcohol y/o de drogas varían según el género y el país: de 11,3% a 50% en personas transexuales hombre-a-mujer (H-M) y de 3,8% a 61,5% en personas transexuales mujer-a-hombre (M-H) (Cole, O'Boyle, Emory y Meyer, 1997;De Cuypere, Janes y Rubens, 1995;Gómez-Gil, Trilla, Salamero, Godás y Valdés, 2009;Haraldsen y Dahl, 2000;Hepp, Kraemer, Schnyder, Miller y Delsignore, 2005;Landen, Walinder y Lundstrom, 1998;Verschoor y Poortinga, 1988). Mientras que en los Países Bajos (Verschoor y Poortinga, 1988), Suiza (Hepp et al., 2005) y los Estados Unidos (Cole et al., 1997) la prevalencia fue superior entre transexuales H-M que en M-H, en Bélgica (De Cuypere et al., 1995) y en Suecia (Landen et al., 1998) fue mayor en el subgrupo M-H; sin embargo, ninguna de estas diferencias resultaron estadísticamente significativas. Un estudio español de nuestro equipo (Gómez-Gil et al., 2009) mostró que la prevalencia de abuso o dependencia en personas transexuales H-M era más alta que en el subgrupo M-H, tanto para el alcohol (10,7% vs. 1,4%) como para otras sustancias (14,5% vs. 1,4%). ...
... [13][14][15][16][17] Two other studies reported a prevalence of 8% and 23% of Axis II Cluster B personality disorders among transgender participants. 18,19 Studies that measured all personality disorders reported a range of 2% to 81%. 15,20,21 These highly inconsistent findings are not surprising, given the methodological differences across studies. ...
... Rather, psychiatric disorders among gender minorities may develop, among other possibilities, in response to the challenges of living as a stigmatized minority in a discriminatory environment. 12,13,[17][18][19][20] In the next section, we describe pathways by which stigma, bias, and discrimination may negatively influence the mental health of gender minorities. ...
As transgender and gender-diverse people are gaining increased visibility in clinical settings, clinicians are requesting better guidance on providing affirming care to improve the mental health and well-being of these patients. In particular, more direction is needed on whether, when, and how to diagnose and treat borderline personality disorder among gender minorities, partially in response to beliefs among some mental health clinicians that a gender minority identity may be a manifestation of identity diffusion. In this Perspectives article, we argue that gender minority identity, even when fluid, is rarely a sign of identity diffusion. By taking a careful history of a patient's gender identity development, the clinician can clarify and gain more conviction regarding the presence of a patient's gender minority identity. Moreover, multiple stigma-related stressors experienced by gender minorities may produce symptoms and behaviors that can mimic or be consistent with certain diagnostic criteria for borderline personality disorder. We therefore conclude with recommendations for adopting a gender-affirming framework to treat borderline personality symptoms when present among gender minority patients, with implications for future research and practice.
... Some cross-sectional studies have also evaluated prevalence estimates of personality pathology in the transgender population [15][16][17][18][19][20][21][22], although research findings on this topic are still mixed and inconclusive. Overall, the prevalence of DSM-IV PDs in samples of medicalized transgender people spreads over a range between 4.3% [16] and 81.4% [21], with some studies [16] reporting a prevalence rate even inferior to what was found in large epidemiological samples [23]. ...
... Overall, the prevalence of DSM-IV PDs in samples of medicalized transgender people spreads over a range between 4.3% [16] and 81.4% [21], with some studies [16] reporting a prevalence rate even inferior to what was found in large epidemiological samples [23]. Cluster B PDs, and particularly borderline and narcissistic PDs, were identified as the most frequently diagnosed Axis II disorders in these samples [18][19][20][21][24][25][26]. ...
The study aims to explore the personality patterns of a group of transgender individuals who accessed an Italian gender clinic to undergo gender affirming treatments, by evaluating both dimensional personality domains proposed by the Alternative Model of Personality Disorders and categorical DSM-IV personality disorder (PD) diagnoses. Eighty-seven participants (40 transgender women and 47 transgender men) completed the Personality Inventory for DSM-5 and the Structured Clinical Interview for DSM-IV Axis II personality disorders. Scores obtained were compared to those of the normative samples of cisgender women and men. Results indicated that transgender women scored lower than cisgender women on two main domains (Negative Affectivity and Psychoticism) and on seven facets. As for transgender men, lower scores than cisgender men were found on Antagonism and on five facets. Transgender men scored higher than cisgender men on Depressivity. Nearly 50% of participants showed at least one PD diagnosis, with no gender differences in prevalence. Borderline PD was the most frequent diagnosis in the overall sample. Self-report measures provide a less maladaptive profile of personality functioning than the clinician-based categorical assessment. Results are interpreted in the light of the Minority Stress Model and support the need for a multi-method assessment of personality in medicalized transgender people.
... At the same time, minority groups such as non-heterosexual individuals (Sandfort et al. 2001) and individuals with gender-dysphoria (Hepp et al. 2005;Toomey et al. 2010) suffer from a greater burden of depressive and anxiety disorders, report poorer life-satisfaction (Powdthavee and Wooden 2015;Davey et al. 2014), and a higher rate of suicide attempts (Haas et al. 2014) compared to heterosexual individuals and individuals without gender-dysphoria. Gender-dysphoria is a clinical condition where individuals experience a persistent discontent over the incongruence between their experienced and assigned gender, leading to significant distress, challenges in social or occupational functioning, and a desire to live a cross-gender life (American Psychiatric Association 2013). ...
... Previous literature indicates higher levels of mental distress among sexual minorities (Sandfort et al. 2001) and gender minority groups (Hepp et al. 2005). The increased rates of mental health problems in these minority populations are often a consequence of the stigma and marginalization attached to living outside mainstream sociocultural norms (Meyer 2003). ...
There is increased mental-health adversity among individuals with autism spectrum disorder. At the same time, sexual and gender minority groups experience poorer mental-health when compared to heteronormative populations. Recent research suggests that autistic individuals report increased non-heterosexuality and gender-dysphoric traits. The current study aimed to investigate whether as membership of minority grouping becomes increasingly narrowed, mental health worsened. The present study compared the rates of depression, anxiety, and stress using the DASS-21 and Personal Well-Being using the personal well-being index between 261 typically-developing individuals and 309 autistic individuals. As membership to a minority group became more restrictive, mental health symptoms worsened (p < .01), suggesting stressors added. Specialized care is recommended for this vulnerable cohort.
... Transgender people have been found to report a high prevalence of depression and anxiety compared to cisgender people (Dhejne, Lichtenstein, & Boman, 2011;Hepp et al., 2005). Competitive sport is an example of an environment that can have negative impacts on the experiences and mental health of transgender people. ...
... SPA can also contribute to maintaining a healthy weight prior to undergoing gender-reassignment surgery (for those who choose to have gender-reassignment surgery; Coleman et al., 2012). Additionally, in context of the high prevalence of depression, anxiety and addiction found amongst transgender people compared to the general population (Dhejne et al., 2011;Hepp et al., 2005), SPA can be particularly important in fostering wellbeing and controlling mental health problems and addictions (Lopez-Canada et al., 2019). Furthermore, Lopez-Canada et al. (2019) found that LGBTQ+ groups can provide an alternative to rigid, sex-segregated physical activity and a safe, friendly and social space for transgender people to exercise. ...
A review of research and policy relating to the inclusion of transgender, intersex and nonbinary people in sport.
... The transgender population has an especially high incidence of sexually transmitted infections, human immunodeficiency virus infection, substance abuse, and psychiatric disorders [22]. In fact, one study found that 39% of patients with gender dysphoria also met criteria for an undiagnosed concurrent psychiatric disorder and 71% of patients were concurrently diagnosed or previously diagnosed with a psychiatric disorder [23]. Despite the high prevalence of medical and psychiatric comorbidities, these patients report improvement from gender affirmation treatment. ...
... Despite the high prevalence of medical and psychiatric comorbidities, these patients report improvement from gender affirmation treatment. A systematic review reported that 78% of patients had significant improvement in psychological symptoms and 80% of patients reported significant improvement in quality of life after treatment [23]. While gender affirmation surgery may alleviate significant distress, it is imperative that medical, psychological, and social obstacles are properly acknowledged and addressed before surgery to confirm that these patients are capable of appropriately continuing care. ...
Purpose of review:
Kidney transplantation and gender affirmation treatments are becoming increasingly more prevalent due to advances in technology. However, there is a paucity of data regarding kidney transplantation in transgender patients. Interesting considerations must be made in this patient population, since there are many hormonal interactions with kidney function and the transplantation process.
Recent findings:
The diagnosis of estimated glomerular filtration rate (eGFR), preoperative assessment/counseling, decreased testosterone levels in a transgender male to female patient, increased estrogen/progesterone in a female to male patient, and drug side effects all have important and unique implications for kidney transplant recipients. Kidney transplantation can be safely and effectively managed in transgender patients with special considerations in eGFR calculations, mental health/lifestyle counseling, and drug interactions.
... Research with people who are diagnosed with gender dysphoria revealed that they are prone to self-mutilation and suicide attempt (Clements-Nolle et al. 2006, Hoshiai et al. 2010, Spack et al. 2012, Turan et al. 2015. Substance abuse, depression, mood disorders, anxiety disorders, somatization, eating disorders are also common among transgendered individuals (Hepp et al. 2005, Hoshihai et al. 2010, Nemoto et al. 2011, Spack et al. 2012, Bockting et al. 2013, Turan et al. 2015. Depression in transgendered individuals is related with lack of social support, transphobia experiences, suicidal ideation, low education, and economic level (Nemoto et al.2011). ...
The purpose of this study was to adapt the Attitudes Toward Transgendered Individuals Scale to use in Turkish population. The study was conducted with 218 university students. Participants were asked to fill out, Genderism and Transphobia Scale, the Attitudes Toward Transgendered Individuals Scale developed by Walch et al., and demographic information form prepared by the researchers. Construct validity of the scale was first tested by exploratory factor analysis (EFA), followed by confirmatory factor analysis (CFA), and criterion validity of the scale was tested by Pearson correlation coefficient. The reliability value of the scale was calculated by Cronbach alpha coefficient. 158 (72.5%) of the participants defined their gender as female, 58 (26.6%) as male, and 1 (.5%) as other. CFA showed that the goodness of fit of the model was satisfactory
... distorce a percepção do gênero;Baltieri & De Andrade, 2009;Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2004).Independentemente da presença ou ausência de um vínculo etiológico, a identidade de gênero pode afetar a forma como uma pessoa TGNC experimenta uma condição de saúde mental que se apresenta em co-ocorrência e/ou uma condição de saúde mental co-ocorrente pode complicar a expressão de gênero ou a identidade de gênero da pessoa. Por exemplo, um transtorno alimentar pode ser influenciado pela expressão de gênero de uma pessoa TGNC (por exemplo, padrões rígidos de alimentação usados para gerenciar a forma do corpo ou menstruação podem estar relacionados à identidade de gênero ou disforia de gênero; Ålgars, Alanko, Santtila, & Sandnabba, 2012;Murray, Boon, & Touyz, 2013). ...
Este documento é a tradução oficial autorizada das Guidelines for Psychological Practice With Transgender and Gender Nonconforming People, elaboradas pela American Psychological Association em 2015. O objetivo desta tradução é disponibilizar ao público de profissionais da psicologia do Brasil material científico informado por evidências para subsidiar boas práticas psicológicas com pessoas trans e em não conformidade de gênero. Existe uma escassez de publicações em português sobre como trabalhar com essa população de modo adequado, assertivo e respeitoso. Considerando o nível de vulnerabilidade, preconceito, exposição à violência e violação de direitos às quais a população trans é submetida no Brasil cotidianamente, é fundamental que profissionais da psicologia possam ter preparo qualificado para acolhê-la e ajudá-la a enfrentar os desafios impostos pelo contexto social hostil no qual está inserida. A maior parte do conteúdo dessas diretrizes pode ser adaptado e adequado à realidade e contexto cultural brasileiros. Porém, alguns trechos dizem respeito às 1 Material publicado originalmente em inglês pela American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832-864. http://dx.doi.org/10.1037/a0039906.
... There has been clear and consistent data showing an increased risk for mood and anxiety disorders in transgender individuals, and there is emerging evidence looking at increased rates of bipolar disorder, post traumatic stress disorder (PTSD), and substance use disorders. [1][2][3][4] Current estimates are based on small sample sizes and, often, self-report surveys. With a national prevalence estimated at 0.033-0.39%, ...
We performed a cross-sectional analysis of the prevalence of psychiatric diagnoses among transgender patients in clinical care using an all-payer electronic health record database. Of 10,270 transgender patients identified, 58% (n=5940) had at least one psychiatric diagnosis compared with 13.6% (n=7,311,780) in the control patient population (p<0.0005). Transgender patients had a statistically significant increase in prevalence for all psychiatric diagnoses queried, with major depressive disorder and generalized anxiety disorder being the most common diagnoses (31% and 12%, respectively). Utilizing an all-payer database, although not without limitations, enables assessment of mental health and substance use diagnoses in this otherwise small population.
... In a recent study of EMR data conducted at Fenway Health [18], case management was identified as a system-level factor that was associated with the utilization of outpatient behavioral health services. This finding suggests improved case management for TGNC patients could also facilitate engagement with behavioral medicine when needed as mental health issues have been shown to be common in the transgender and nonbinary patient populations [19][20][21]. ...
Transgender and gender nonconforming (TGNC) patients have been seeking medical care in higher numbers and have faced unique social, personal, and health issues that affect the quality of care they receive. The purpose of this study was to conduct a mixed-methods study to describe TGNC care at Kaiser Permanente Mid-Atlantic States, a large integrated health system. We used a transgender registry to describe a TGNC patient population and compared healthcare utilization between TGNC patients and non-TGNC patients. Four focus groups were also conducted among 28 patients. Atlas.ti software was used to code and analyze themes for the qualitative analysis. Among the 282 adults TGNC patients, the mean age was 32.6 years. Of the study sample, 59% were White, and 27% were Black. TGNC patients demonstrated an increased use of email/telephone visits and the online patient portal and more cancellations and no-shows compared to non-TGNC controls. Of the 28 TGNC patients who participated in the focus groups, 39% identified as female, 21% as a transman, and 18% as non-binary/genderqueer. Participants were predominantly White (68%), highly educated (74%), and reported use of hormones (89%). Themes that emerged from our qualitative analysis included: limited availability of TGNC information; positive and negative sentiments regarding patient-provider interactions; issues with case management; limited access to care; lack of coordination of care; negative staff experiences. We identified specific areas in a health system to improve the quality of care of TGNC patients, including specific TGNC training for providers and staff, a source of TGNC information/resources, and hiring and training TGNC-specific case managers.
... However, this was a non-referred group and may not be generalizable to all children with gender dysphoria. Studies on pubertal adolescents with gender dysphoria found a high prevalence of psychiatric comorbidity and risk for suicidal ideations compared to the general population (Budge, Adelson, & Howard, 2013;de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011;Grossman & D'Augelli, 2007;Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005;Jones, Robinson, Oginni, Rahman, & Rimes, 2017;Veale, Watson, Peter, & Saewyc, 2017;Virupaksha, Muralidhar, & Ramakrishna, 2016). A factor that is well known to be related with psychopathology is low self-esteem (Isomaa et al., 2013;Sowislo & Orth, 2013). ...
Transgender children and adolescents show high rates of co-occurring psychopathology, which might be related to low self-confidence. Earlier research showed that compared to the norm population, transgender clinic–referred children have lower self-perception on two domains: physical appearance and global self-worth. This study aimed to compare self-perception in a sample of transgender clinic–referred children and adolescents with their standardization samples and to examine differences between these two groups. To measure self-esteem, the Self-Perception Profile for Children was administered to 305 referred children (162 assigned males at birth (AMABs) and 143 assigned females at birth (AFABs), mean age = 9.05 (SD, 1.47), range = 5.9–13.00 years), and the Self-Perception Profile for Adolescents was administered to 369 referred adolescents (118 AMABs and 251 AFABs, mean age = 15.27 (SD, 1.80), range = 10.73–18.03 years). To measure the severity of gender dysphoria, the parents of the children completed the Gender Identity Questionnaire and the adolescents completed the Utrecht Gender Dysphoria Scale. Referred children and adolescents had a significantly lower self-concept compared to the normative population, whereby referred adolescents felt less competent compared to referred children. Compared to their peers, childhood referred AFABs perceived themselves even better on scholastic and athletic competence and social acceptance. With regard to gender differences, referred AFABs generally showed a better self-perception compared to referred AMABs. The lower self-perception of transgender clinic–referred children and adolescents compared to same age peers deserves clinical attention and interventions aimed at, for example, improving social and physical self-worth.
... They are likely to suffer from depression, anxiety disorder, specific phobia, and adjustment disorder. [2,9,10] It is important to note that many patients with GID may show a high score in at least one MMPI subscale other than the Mf scale. [11] Patients with GID are often ridiculed, bear stigma, and face rejection within close family circles. ...
Background:
Gender identity disorder (GID) is a distressing disorder characterized by a persistent unhappiness with one's own gender and a desire to be of the opposite gender as well as seeking sex reassignment surgery for the same. The aim of the study was to assess the Minnesota Multiphasic Personality Inventory (MMPI) profiles in patients with GID and compare with healthy normal population and also examine differences in the profiles based on original gender of the patients.
Materials and methods:
A total of 56 patients with GID that fulfilled the Diagnostic and Statistical Manual of Mental Disorders 5 criteria for the same were participants of the study, and there were 54 control participants. They were administered the MMPI, and the scores across various scales were statistically analyzed.
Results:
It was seen that apart from masculinity feminity (Mf) scale, other scales such as Paranoia (Pa, P < 0.01), Schizophrenia (Sc, P = 0.01), and Psychopathic deviate (Pd, P < 0.01) were also elevated in many patients. Male patients seeking surgery to become female showed higher scores on Pa and Sc scales than female patients. On detailed inquiry, it was found that there was no evidence of psychosis clinically, and in fact, their paranoia was reality based.
Conclusion:
MMPI profiles in patients with GID needs to interpreted with caution and clinicians must keep in mind that elevated Pa and Sc scales on the MMPI in these patients need not indicate a psychotic profile.
... Due to some overlapping symptoms (dysphoric mood, functional decline), GD is often confused with mood disorders. Mood and anxiety disorders were reported to be the most common psychiatric diagnoses in transgender individuals (a Campo et al. 2003;Hepp et al. 2005;Heylens et al. 2014;Dhejne et al. 2011) and they could complicate GD, causing poor treatment outcomes. However, more recent studies in this area show that GD was not associated with other Axis-I diagnoses, supporting GD being distinct from other mood disorders including major depressive disorder (Heylens et al. 2014). ...
Gender identity development is complex and involves several key processes. Transgender people experience incongruence between their biological and identified gender. This incongruence can cause significant impairment in overall functioning and lead to gender dysphoria (GD). The pathophysiology of GD is complex and is poorly understood. A PubMed search based on predetermined eligibility criteria was conducted to review neuropsychiatric articles focused on neurological, biological and neuroimaging aspects of gender development, transgender identity and GD. The information obtained from the literature was then used to formulize a GD model. Distinct gray matter volume and brain activation and connectivity differences were found in individuals with GD compared to controls, suggesting a neurobiological basis of GD; which leads to the concept of brain gender. Individuals with GD encounter a recurrent conflict between their brain gender and the societal feedback; which causes recurrent and ongoing cognitive dissonance, finally leading to GD and functional connectivity and activation changes in the transgender brain. GD has neurobiological basis, but it is closely associated with the individuals’ interaction with the external world, their self-perception and the feedback received in return. We propose a novel model where the development of GD includes cognitive dissonance, involving anterior cingulate cortex and ventral striatum as the key brain structures. This model can be used to generate testable hypotheses using behavioral and neuroimaging techniques to understand the neuropsychobiology of GD.
... Trans people are just as likely to seek care for other mental health concerns (e.g., stress at work, relationship concerns, depression, anxiety) as are cisgender people. 2 There are several important aspects of working with trans clients that are important to keep in mind. Clients might seek care to address questions they have about their gender identity, trans clients might seek care for a clinical concern unrelated to their gender identity, some clients will seek care because of a connection between their gender identity and stressors they are experiencing (Hendricks & Testa, 2012), and in rare cases a client might seek care for a mental health concern that mimics gender identity concerns (APA, 2015; Baltieri & De Andrade, 2009;Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005). A final consideration is the need to explore the ways that a person's intersecting identities are impacting their experiences as a trans person. ...
... Desire for sex reassignment surgery. Schizophrenia, depression, dissociative disorders, anxiety disorders, adjustment disorders, substance abuse disorders and personality disorders are frequently co-morbid with gender dysphoria [8][9]. GD has been described in nearly every race and culture. ...
Gender dysphoria (GD), previously called as Gender identity disorder (GID), is a rare condition characterized by an incongruity between gender identity and biological sex. We present a case of an adult, biological male diagnosed schizophrenia with gender dysphoria. The present case supports this view as the patient showed features of GD much before the onset of schizophrenia and the latter subsided with the treatment but not the former. This may suggest that the GD is a comparatively stable belief of sex change and the schizophrenic symptoms occurred as florid exacerbation of the trait. This article explores the concept of gender dysphoria and the role of psychological interventions in its management. A case of gender dysphoria with co-morbid schizophrenia is reported here.
... is the most commonly reported comorbidity (Hepp et al., 2005;Neziroglu & Yaryura-Tobias, 1997). Therefore, the repetitive conviction in GID of belonging to the opposite sex and the suffering from the subsequent physical non-match, continuously experienced have much in common with obsessive compulsive symptoms. ...
Individuals with Body Integrity Identity Disorder (BIID) have the strong feeling that one or more healthy limbs do not belong to their body. Due to the incongruity between physical and perceived body they desire amputation of the non-belonging, unwanted limb(s). This desire for amputation constitutes a source of serious suffering. Currently, there is no consistent opinion about the underlying causes of BIID, and potential treatment options are controversially discussed. The general purpose of the present thesis was to investigate the neurological, neuropsychological and psychiatric characteristics of BIID. Specifically, we hypothesized that the unwanted limb is misrepresented in the brain and/or that the integration of multisensory information about the unwanted limb(s) may be disrupted at some processing stage. A series of behavioral experiments and a structural neuroimaging investigation were planned to address this hypothetical limb representational deficit. The investigation comprised three standardized clinical examinations (neuropsychological, neurological and psychiatric), five behavioral experiments (mental limb rotation, body transformation and task switching, rubber foot illusion, caloric vestibular stimulation and tactile temporal order judgments (TOJ)) as well as magnetic resonance imaging (MRI) in 15 individuals with BIID and 15 paired-matched control subjects. Neurological, neuropsychological and psychiatric exams revealed normal functions in persons with BIID. While we failed to accumulate evidence for limb representational deficits in BIID in four behavioral experiments, a fifth experiment (TOJ) uncovered a disturbed spatio- temporal integration of tactile information in the unwanted compared to the accepted body part. The MRI investigation revealed gray matter morphological differences in circumscribed brain areas (right superior parietal lobule (SPL), right primary and secondary somatosensory cortex (SI and SII), right anterior insular cortex and both putamina) between the two participant groups. We conclude that (1) BIID occurs in neurologically, psychiatrically and neuropsychologically grossly healthy persons, (2) tactile information from unwanted compared to accepted body parts is differently integrated at higher-order areas of body representation and (3) observed gray matter characteristics in persons with BIID may constitute a correlate of altered processing both at low-level stages (diminished limb representation in SI, SII and putamen) and higher-order stages of multisensory integration (defective "binding" of a body part into a coherent whole-body representation in the SPL and altered emotional connotations in the anterior insula). Together, the findings of the present thesis present evidence for an altered neuroanatomy in persons with BIID, which may lead to the feeling of non-belonging of the unwanted limb. This evidence should free the condition from its apparent bizarreness and from psychiatric mystifications. Zusammenfassung Personen mit Body Integrity Identity Disorder (BIID) haben das intensive Gefühl, dass eine oder mehrere Gliedmassen nicht zu ihrem Körper gehören. Aufgrund der Nicht- Übereinstimmung zwischen physischer und empfundener Körperform wünschen sie eine Amputation der ungewollten Gliedmasse. Der Wunsch nach Amputation wird als starke psychische Belastung erlebt. Gegenwärtig gibt es keine übereinstimmende Meinung über die Ursachen, die BIID zugrunde liegen und potentielle Behandlungsmethoden werden kontrovers diskutiert. Ziel der vorliegenden Dissertation war es, neurologische, neuropsychologische und psychiatrische Merkmale von BIID zu untersuchen. Im Besonderen nehmen wir an, dass die ungewollten Gliedmassen mangelhaft im Gehirn repräsentiert sind. Mit einer Reihe von Verhaltensexperimenten sowie struktureller Bildgebung des Gehirns (Magnetresonanztomographie, MRT) wollten wir dieses hypothetische Defizit der Gliedmassen-Repräsentations prüfen. Die Studie bestand aus drei standardisierten klinischen Untersuchungen (neuropsychologisch, neurologisch und psychiatrisch), fünf Verhaltensexperimenten (Mentale Rotation von Gliedmassen, Körpertransformation und Aufgaben-Umstellfähigkeit, Gummifuss-Illusion, kalorisch-vestibuläre Stimulation und taktile Stimulation für die Beurteilung zeitlicher Abfolgen) sowie einer MRT Untersuchung bei 15 Personen mit BIID und 15 paarweise zugeordneten Kontrollprobanden. In den klinischen Standarduntersuchungen ergaben sich unauffällige Funktionen bei Personen mit BIID. Während sich in vier Verhaltensexperimenten keine Hinweise auf ein Defizit der Gliedmassen-Repräsentation zeigten, konnte eine gestörte räumlich-zeitliche Integration von taktiler Information auf der ungewollten im Vergleich zur akzeptierten Gliedmasse entdeckt werden. Die MRT Untersuchung ergab Gruppenunterschiede in umschriebenen Arealen der grauen Substanz (rechter superiorer Parietallappen (SPL), rechter primärer und sekundärer somatosensorischer Kortex (SI und SII), rechte anteriore Insel sowie beide Putamina). Wir schliessen daraus, dass (1) BIID in neurologisch, psychiatrisch und neuropsychologisch gesunden Personen vorkommt, dass (2) taktile Stimulation der ungewollten verglichen zur akzeptierten Gliedmasse fehlerhaft integriert wird, was einem Verarbeitungsdefizit auf höherem Integrationsniveau entspricht und dass (3) die beobachteten Unterschiede in der grauen Substanz ein Korrelat von veränderten Funktionen sein könnten, welche einfachere Verarbeitungsstufen (verminderte Gliedmassen-Repräsentation in SI, SII und Putamen) wie auch komplexere Verarbeitungsstufen von multisensorischer Information betreffen (fehlerhafte Ganz-Körper-Repräsentation im SPL und veränderte emotionale Besetzung in der anterioren Insel). Zusammen weisen die Ergebnisse der vorliegenden Dissertation auf eine veränderte Neuroanatomie in Personen mit BIID hin, welche zum Gefühl der Nicht- Zugehörigkeit der ungewollten Gliedmasse führen mag. Diese Befunde sollten helfen, BIID den Stempel des Absonderlichen zu nehmen und vor einer voreiligen Psychiatrisierung zu schützen.
... They may be at higher risk of poor psychological functioning and less equipped to develop adaptive coping strategies in the society because of their experiences of gender-related discrimination, rejection and other negative responses from others (Earnshaw and Chaudoir 2009;Wang et al. 2014). Compared with previous research, some studies showed similar results with this study (Hepp et al. 2005), while some studies have reported that few transgender people were in the clinical range regarding their personality profiles (Smith et al. 2005;Keo-Meier et al. 2015). The differences in similar studies may be related to the sexual orientation, status in the process of sex-reassignment treatment and so forth among transgender individuals (De Vries et al. 2011). ...
This study assessed the depression status of transgender individuals and their personality profiles for seeing the psychological functioning. We further compared their status with cisgender individuals and explored the role of personality profiles in explaining
the variance of depression level among transgender and cisgender individuals. Seventy-one transgender individuals and seventy-three cisgender individuals were investigated in Shanghai Mental Health Centre. The general depression level and personality profiles of
transgender individuals remained normative range, but percentages of transgender individuals who reported moderate or major symptoms and poor personality profiles were significantly higher than those of cisgender counterparts. Subscale scores of paranoia
and psychopathic deviate significantly contributed to the variance of depression level among transgender people in multiple regression model. This study sheds light on the psychological needs of transgender people, which provided healthcare providers with the
implications of developing psychological intervention programmes and mental health services.
... Budge and others in their qualitative study indicate that distress varies on the basis of several factors, including the individual's transition process, coping mechanisms used, and level of social support. Although both of these studies provide insight into possible explanations for contributing factors to transgenders individuals' distress, there continues to be a lack of generalizable information regarding the actual process through which individuals cope with and experience depression and anxiety [36]. ...
... Previous studies have found that personality psychopathology is higher in GSM populations (Russell et al. 2017) and transgender individuals (Hepp et al. 2005). Therefore, parental rejection may act as a catalyst for these higher rates, and parental acceptance can buffer from personality psychopathology's adverse effects. ...
The construct of Parental Acceptance-Rejection (PAR) impacts a person’s mental health and well-being well into adulthood and has many adverse outcomes. Sexual orientation minorities are at particular risk for parental rejection. Sexual orientation minorities who experience parental rejection are at risk for substance use, internalized homophobia, and a disrupted sense of identity. Furthermore, regardless of PAR, the sexual orientation minority population already has an increased risk of mental health issues, notably higher personality psychopathology rates. However, no research has examined the role of PAR on personality psychopathology in sexual orientation minority populations. This study examined the association between PAR and personality psychopathology and impairment in a sample of 79 people whoself-identify as sexual minorities. Significant correlations were found between parental rejection and rates of pathological personality traits and impairment. Identity-related moderators were examined, and multiple interaction effects were identified. Implications and future directions are discussed.
... The persistent sense of discrepancy that people with GD feel about their assigned gender and their felt gender posts them in a vulnerable situation, due to a continuing dissatisfaction with and a rejection of their own primary and secondary sexual characteristics. This may represent a risk factor for suicidal behaviours, as various studies have found that GD is associated with an increased number of suicides compared to the general population (Bodlund & Kullgren, 1996;Clements-Nolle et al., 2006;Hepp, Kraemer, Schnyder, Miller & Delsignore, 2005;Jiménez Zarazúa et al., 2015). ...
Background:
The little research there is about suicidal behaviour in those with gender dysphoria indicates that they are at a much higher risk of death by suicide and suicidal behaviour than the general population. The objective of this research is to analyse the prevalence of suicidal ideation and suicide attempts reported by people who attended consultations at the Gender Identity Treatment Unit between 2007 and 2017 presenting complaints related to gender dysphoria.
Method:
An ex-post facto study with a sample of 151 people who were clients at the unit, 97 in the male to female trans group, 54 female to male. Clinical evaluations were carried out assessing variables of suicidal ideation and attempts, along with a possible psychiatric diagnosis.
Results:
Almost half (48.3%) reported suicidal ideation, 23.8% had attempted suicide.
Conclusions:
There are higher levels of suicidal ideation and suicide attempts in people with gender dysphoria than in the general population. No differences were seen between groups in terms of gender/sex. Psychiatric morbidity was not an influential variable for suicidal behaviour. This suggests that suicidal ideation is one of the best indicators of the risk of suicidal behaviours.
... The highest prevalence was reported in EMR studies -specifically in US studies of transgender adolescents accessing gender affirming care in an urban center, Medicare beneficiaries, and Veteran Health Administration patients (mood disorder: up to 82%; anxiety disorder: up to 67%) (Nahata et al., 2017). However, substance use disorder estimates varied more by study type, with the highest prevalence (50%) reported by a lifetime measure among transgender women (n = 20) with a gender identity diagnosis in a Swiss crosssectional clinical study of psychiatric morbidity (Hepp et al., 2005). ...
Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.
... Some studies have shown that psychiatric problems are more common in patients with GD (a Campo, Nijman, Merckelbach, & Evers, 2003;Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005;Heylens et al., 2014a). Not surprisingly, we found that FtM GD participants' baseline scores for all SCL-90-R subscales (except for Phobic Anxiety) were significantly higher than female controls. ...
Body dissatisfaction plays an important role in the development of psychiatric problems such as eating disorders as well as gender dysphoria (GD). Cross-sex hormonal treatment (CHT) alleviates the dissatisfaction by making various changes in the body. We examined the alteration of body uneasiness, eating attitudes and behaviors, and psychological symptoms longitudinally in Turkish participants with female-to-male gender dysphoria (FtM GD) after CHT. Thirty-seven participants with FtM GD and 40 female controls were asked to complete the Body Uneasiness Test to explore different areas of body-related psychopathology, the Eating Attitudes Test to assess eating disturbances, and the Symptom Checklist-90 Revised to measure psychological state, both before CHT and after 6 months of CHT administration. The baseline mean body weight, BMI scores, body uneasiness scores, and general psychopathological symptoms of participants with FtM GD were significantly higher than female controls, whereas baseline eating attitudes and behaviors were not significantly different. Over time, FtM GD participants’ mean body weight and BMI scores increased, body uneasiness and general psychopathological symptoms decreased, and eating attitudes and behaviors had not changed at 24th weeks following CHT administration compared to baseline. CHT may have a positive impact on body uneasiness and general psychopathological symptoms in participants with FtM GD. However, CHT does not have an impact on eating attitudes and behaviors.
... Desire for sex reassignment surgery. Schizophrenia, depression, dissociative disorders, anxiety disorders, adjustment disorders, substance abuse disorders and personality disorders are frequently co-morbid with gender dysphoria [8][9]. GD has been described in nearly every race and culture. ...
Gender dysphoria (GD), previously called as Gender identity disorder (GID), is a rare condition characterized by an incongruity between gender identity and biological sex. We present a case of an adult, biological male diagnosed schizophrenia with gender dysphoria. The present case supports this view as the patient showed features of GD much before the onset of schizophrenia and the latter subsided with the treatment but not the former. This may suggest that the GD is a comparatively stable belief of sex change and the schizophrenic symptoms occurred as florid exacerbation of the trait. This article explores the concept of gender dysphoria and the role of psychological interventions in its management. A case of gender dysphoria with co-morbid schizophrenia is reported here.
... More precisely, gender identity minorities report less peer and family support than sexual minorities, 2 which may also contribute to their higher vulnerability for mental health impairments (6). It is reported that trans populations in the U.S. have an increased lifetime prevalence of depression (range: 48-62%) (7,8) and anxiety (range: 26-38%) (9) when compared to the general population (depression: 16.6%, combined anxiety disorders: 28.8%) (10). With a range from 28 to 40%, the prevalence of suicidal ideation (SI) and suicide attempts (SA) among trans individuals is extremely high (11). ...
Discrimination heavily impacts the lives of trans populations and causes adverse mental health outcomes. As stated by the Gender Minority Stress Model self-stigmatization could play an important role in this process. The aim of this systematic review is to investigate whether there is a positive association between self-stigmatization and mental health and to identify mediation factors. Studies which quantitatively investigated the association between internalized transnegativity and selected mental health outcomes (depression, anxiety, non-suicidal self-injury, suicidal tendency) in self-identified trans populations were included. Comprehensive search of 5 large databases in June 2020 and the following screening and selection procedure, performed by two researchers separately, identified 14 studies which met criteria. The relationship to be studied was reported with correlation and/or mediation analysis of cross-sectional data. IT was directly positively associated with depression, anxiety and suicidal tendency in most of the reviewed studies. Data indicates links between self-stigmatization and other general mental health stressors such as rumination and thwarted belongingness. Community connectedness showed to be the strongest protective factor for mental health impairments. These results should be considered in transition counseling. More research is needed to better understand the underlying mechanisms of the GMSM and to address unsolved operationalization and measurement issues.
... Individual, familial, and social factors may interact in different ways to develop somatic symptom disorder (18)(19)(20). Association between GD and SSD has already been described (21). Children and adolescents often secretly hide their feelings related to gender non-conformity. ...
Background: Somatic symptom disorder is common in children and adolescents; usually, it is an expression of a mental health problem or other conditions that lead to psychosocial impairment and suffering. Among these, in pubertal age, gender dysphoria should be considered.
Case Presentation: We present the case of a 15-year-old girl admitted to the hospital because of a 2-month history of scattered arthralgia and myalgia, headache, and fatigue, with repeated visits to the emergency room. The physical exam was unremarkable, except for step walking and pain. Repeated diagnostic tests were normal, and consecutive psychological interviews disclosed intense suffering due to a gender incongruence. Referral to the hospital gender service was offered and refused by the parents.
Conclusions: In pubertal age, gender dysphoria may be expressed through somatoform symptoms. Diagnosis is challenging to accept for the parents even in the presence of adequate multi-disciplinary hospital services.
... Numerous studies have shown increased rates of depression in transgender populations. [25][26][27] In a study of 191 transgender women in Ontario, depression was estimated at 61%. 28 Anxiety in transgender women is less well studied and is typically not the primary endpoint when it is included in research. In a 2013 study of coping mechanisms in transgender individuals, 40% of transgender women had anxiety symptoms. ...
Although sexual minority women (SMW)and transgender women have become increasingly visible in recent years and have made progress in achieving civil rights, they continue to face significant levels of discrimination, stigma, and physical violence. As a result, each group faces a wide variety of health disparities, including mental illness and substance use disorders. Overall, both SMW and transgender women experience higher rates of mood and anxiety disorders, suicidality, and substance use disorders than their heterosexual and cisgender counterparts. This article is a general introduction to these issues and concludes with recommendations for working with sexual minority and transgender women.
Gender dysphoria in individuals with schizophrenia may result from the delusionally changed gender identity or appear regardless of psychotic process. Distinguishing between these situations is not only a diagnostic challenge, but also affects the therapeutic decision-making. The review of the literature shows that different delusional beliefs regarding belonging to another gender, anatomy or changes within the genitals affect about one-fourth of patients with schizophrenia. Contemporary classifications of disorders are moving towards the elimination of psychotic disorders as a disqualifying criterion in diagnosing gender dysphoria. It is also established that schizophrenia may change the picture of gender dysphoria, e.g., by giving meaning and delusional interpretations of the fact of the incompatibility of phenotypic sex with the sense of gender. At the same time, before making a therapeutic decision (especially aimed at gender reassignment), it is necessary to exclude the psychotic background of the desire for gender reassignment. In case of co-occurrence of both disorders, it is crucial to evaluate the chronology and dynamics of the individual symptoms, their constancy (prolonged observation), patient's criticism and response to antipsychotic treatment.
Introduction:Individuals with gender identity disorder (GID) experienceseries of adjustment problems in society before and after sex reassignment surgery. The aim of this study was to compare self-harm and defense mechanisms before and after sex reassignment surgery in these persons.
Method: We used a case- control design, in quantitative stage 30 people with GID before surgery and 30 people with GID after surgery and normal people were investigated.
Results:Data analysis by a Multivariate analysis of variance were showndecreasedtrend of directly self-harm behaviors after surgery, whereas there were not any differences in indirect self-harm behaviors before and after surgery. No differences was found in neurotic and mature defense mechanisms between groups.
Conclusion: It seemthat the sex reassignment surgery could effectivelydecreasethe directly self-harm and immature defense mechanisms, while it has no effect in changing indirect self-harm, neurotic and mature defense mechanisms. It could be concluded that indirect self-harm sustains even after sex reassignment surgery that need to be targeted with psychological and social interventions. Changing in the immature defense mechanisms could be considered as a valid indicator of physical and psychological treatments.
The post-Finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat hair loss or benign prostatic hyperplasia. While the incidence of persistent sexual, mental, and physical side effects despite quitting finasteride is unknown, and the condition is not recognized by the scientific community, individuals who suffer from PFS do present with very distinctive and homogenous symptoms. The concept has emerged from reports of nondermatologists, neuroendocrinological research, case reports, and uncontrolled studies. These have been scrutinized by hair experts who found that persistent sexual side effects were only documented in low-quality studies with a strong bias selection and a significant nocebo effect. Others totally dispute the credibility of the PFS. In any case, the PFS is a problem that has to be dealt with. Low-quality studies neither confirm nor refute the condition as a valid nosologic entity. Therefore, it is as inappropriate to dismiss the condition, as it would be to demonize finasteride for the treatment of male pattern hair loss. Whether the PFS represents a nocebo reaction or a real drug adverse event is irrelevant, while the best way to alleviate the emotional distress related to hair loss is to effectively treat the condition causing the problem. It is not sufficient to only discuss the plausibility of the PFS. There is a need for practical recommendations to include such important issues as patient selection and risk assessment, appropriate patient information, how to react in case of drug-related adverse events, issues of fertility and malignancy, management of the PFS, and alternatives, specifically the use of topical finasteride. It is the aim of this commentary to provide the respective information. © 2019 International Journal of Trichology | Published by Wolters Kluwer - Medknow.
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.
When transgender people most need help, many face hostility and inadequate care from their health providers, including psychologists. This hostility is not surprising given widespread lack of familiarity with transgender issues or perspectives amongst clinicians. Even amongst those who hold the stance of openness to the other, most still have considerable difficulty working with transgender clients. Transgender training efforts vary in quality; some even appear to worsen attitudes towards transgender clients. Given these risks, it is crucial that clinical training directors and supervisors evaluate trainees’ abilities to facilitate respectful initial conversations with transgender clients. This project proposed an objective instrument for assessing a mental health clinician, or clinical trainee’s ability to discriminate between helpful and unhelpful responses commonly made in the initial clinical encounters with transgender clients. Development of the instrument is grounded in a combination of theoretical and empirical
literature on the topic and is synthesized with the personal and professional experiences of the primary researcher as a transgender person and emerging clinician. This study utilized systematic expert review to examine the validity of this proposed instrument. This dissertation is available in open access at AURA, http://aura.antioch.edu/ and Ohio Link ETD Center, https://etd.ohiolink.edu/etd
Keywords: transgender, clinical training, multicultural competency, test development
Zusammenfassung
Einleitung Am 9. Oktober 2018 wurde die Leitlinie „Geschlechtsinkongruenz, Geschlechtsdysphorie und Trans-Gesundheit: Diagnostik, Beratung und Behandlung“ nach methodischer Prüfung von der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) mit S3-Status in das Leitlinienregister aufgenommen und online veröffentlicht.
Forschungsziele Die Leitlinie verfolgt das Ziel, die „Standards zur Begutachtung und Behandlung von Transsexuellen“ aus dem Jahr 1997 an die gegenwärtigen Bedingungen und Forschungsergebnisse anzupassen und sie für eine adäquate Versorgung in Deutschland nutzbar zu machen.
Methoden Die Behandlungsempfehlungen der Leitlinie basieren auf empirischer Evidenz, die systematisch recherchiert und bewertet wurde. Die für den Kreis der Adressat_innen repräsentative Leitliniengruppe hat gemeinsam mit einer Interessensvertretung von trans Menschen im Zuge einer strukturierten Konsensfindung 100 Empfehlungen konsentiert.
Ergebnisse Die Leitlinie soll das Feld der Trans-Gesundheitsversorgung individualisieren und damit auch deregulieren. Optionen für eine zielführende Behandlung der Geschlechtsinkongruenz und/oder Geschlechtsdysphorie werden aufgezeigt. Anschließend wird ein empirisch und klinisch fundiertes Vorgehen empfohlen, das auf individuelle Bedingungen bei der Behandlung bedarfsgerecht eingehen kann.
Schlussfolgerung Die Leitlinie reflektiert aktuelle internationale Standards der Trans-Gesundheitsversorgung auf Basis empirischer Evidenz und bezieht sie auf das deutsche Gesundheitssystem. Ihre Anwendung sollte mit klinisch-therapeutischer Expertise abgesichert werden.
The review examines the mental illnesses most commonly found in individuals with gender identity disorders. The applicability of Meyer’s Minority Stress Model (1995) to explanation of the observed comorbidity is analyzed. In conclusion the need for increased attention to persons with gender identity disorders from psychological and psychiatric services is stated.
The chapter deals with female sexual dysfunctions and gender dysphoria/incongruence in women. Concept, classification, clinical presentation, diagnosis and differential diagnosis, and treatment are the aspects addressed for each of these two categories. Preceding this content, the chapter considers the female sexual response cycle and its relation to the classification of female sexual dysfunction. This model also emphasizes the importance of emotional satisfaction during sexual activity and recognizes that female sexual functioning is more complex and is less linear than male sexual functioning. Another aspect that has received special mention in this chapter was the Brazilian program of assistance to transgender people, currently being updated by the experts. Nevertheless, the fundamental challenge remains as to how the standards of care will be negotiated, approved, and implemented by the public and private health authorities of various countries, in the context of broader sociopolitical issues. The whole text of the chapter is supplemented by diagnostic and therapeutic schemes that summarize these topics, to facilitate apprehension.
The medical needs of the transgender population are increasingly recognized within the American health care system. Hormone therapy and gender‐affirming surgery present distinct anatomic, hormonal, infectious, and psychosocial issues among transgender kidney transplant donors and recipients. We present the first reported experience with kidney transplantation and donation in transgender patients. A single‐center case series (1/2014‐12/2018) comprising four transgender kidney transplant recipients and two transgender living donors was constructed and analyzed. Experts in transplant surgery, transplant psychiatry, transplant infectious disease, pharmacy, and endocrinology were consulted to discuss aspects of care for these patients. Four transgender patients identified as male‐to‐female and two as female‐to‐male. Three out of six had gender‐affirming surgeries prior to transplant surgery, one of whom had further procedures posttransplant. Additionally, four patients were on hormone therapy. All six had psychiatric comorbidities. The four grafts have done well, with an average serum creatinine of 1.45 mg/dL at two years (range 1.01‐1.85 mg/dL). However, patients encountered various postoperative complications, one of which was attributable to modified anatomy. Thus, transgender kidney transplant patients can present novel challenges with regards to surgical considerations as well as pre‐ and posttransplant care. Dedicated expertise is needed to optimize outcomes for this population.
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This paper presents research on the enforcement and impact of the first legal gender recognition legislation in Portugal (Law no.7/2011). The study describes how the administrative process created by the law functioned during its initial 5-year period, and identifies challenges and processes of resistance to this legal innovation. Simultaneously, it seeks to assess the impact of the law on the social and psychological well-being of trans people, including in their access to vital spheres of social life such as education and employment. The research employs a mixed-methods approach and a multi-informant methodology: an online questionnaire was completed by 68 trans and non-binary people, and semi-structured in-depth interviews were carried out with various selected stakeholders: representatives of trans and LGBTIQ+ organisations (n=5), health professionals identified as experts in the topic and as gatekeepers in legal gender recognition processes (n=12), and trans people (n=6). Results show, on the one hand, the significant positive impact that legal gender recognition has on the psychological well-being and social welfare of the participants. On the other hand, results also show several challenges and forms of resistance to the implementation of the law, in particular those challenges resulting from the fact that legal gender recognition depended on a clinical diagnosis and the provision of a clinical report.</p
The clinical characteristics of 13 patients with Gender Dysphoria (GD) admitted to a mixed gender secure psychiatric hospital for adolescents were analysed. The main finding was that all 13 patients were biologically female but identified as being male, at least some of the time. The clinical characteristics of the patients were very similar to those of female patients admitted to the service without gender identity issues. There are no other published studies of Gender Dysphoria within secure hospitals.
Background
Gender-affirming hormone therapy for transgender women includes estrogen and antiandrogens (cyproterone acetate, spironolactone, or gonadotropin-releasing hormone agonists). Both estrogen and antiandrogens are reported to increase prolactin levels. The objective is to systematically review the evidence of the effects of antiandrogens on prolactin levels, hyperprolactinemia, and prolactinomas among transgender women on estrogen therapy.
Methods
We searched PubMed, Embase, and PsycInfo up to May 2020. We included studies with at least 3 months follow-up that evaluated the effects of antiandrogens among transgender women and reported on prolactin levels, hyperprolactinemia, or image-confirmed prolactinomas. Two reviewers independently screened studies for eligibility, serially abstracted data, and independently assessed risk of bias and graded strength of evidence.
Findings
We included 17 studies (16 publications): 8 prospective cohorts, 8 retrospective cohorts, and 1 cross-sectional study, each with a moderate to serious risk of bias. Among transgender women on estrogen, prolactin levels increased by over 100% with cyproterone acetate and by up to 45% with spironolactone. However, we were unable to isolate the effects of antiandrogens from estrogen therapy. We were unable to draw conclusions about effects of antiandrogens on hyperprolactinemia and prolactinomas.
Interpretation
Prolactin levels may be increased in transgender women who are taking both estrogens and an antiandrogen. Future research is needed to determine the effects of different antiandrogens on prolactin levels separately from estrogen therapy. Ideally, future studies would be prospective, provide either a comparison of two different antiandrogens or compare combination of estrogen and antiandrogen therapy to estrogen alone, and control for possible confounders.
In questo articolo gli autori esamineranno l'attuale situazione italiana per quanto concerne i trattamenti di conferma del genere (GCT) e, alla luce delle ulti-me ricerche e review della letteratura sui GCT, verranno analizzate e confrontate le linee guida dell'Osservatorio Nazionale sull'Identità di Genere (ONIG) e della World Professional Association for Transgender Health (WPATH). Gli autori mostreranno come l'attuale percorso, che prevede, prima dell'accesso ai GCT, la risoluzione di ogni altro disagio psichico presente, potrebbe essere modificato per mi-gliorare lo stato di benessere delle persone transgender e gender non-conforming (TGNC), trattando la disforia prima o contemporaneamente ai disturbi secondari. Si evidenzierà inoltre come la popolazione affetta da disforia di genere risulti par-ticolarmente suscettibile allo sviluppo di disturbi psichiatrici, con evidenti costi in termini di qualità di vita per la persona e per il sistema sanitario che deve farsene carico. Infine, verrà evidenziato che il miglioramento dei servizi sociosanitari per le persone transgender contribuirebbe a migliorare la qualità della vita della popola-zione TGNC italiana anche grazie ad una depatologizzazione delle identità non coerenti col genere assegnato.
This study examined the associations between minority stressors, poor mental health, and sexual risk behaviors, and whether there were interactive effects of minority stress and mental health factors in their associations with sexual risk behaviors in a sample of Chinese transgender women sex workers (TGSW). A cross-sectional study was conducted in 204 TGSW in Shenyang, China (mean age 33.4 years and 18.1% self-reported as HIV positive). We found a high prevalence of condomless anal intercourse (CAI) with male clients (27.9%) and CAI with male regular partners (49.5%) in the past three months among TGSW. Multivariate logistic regression analysis showed that discrimination, victimization, and life dissatisfaction were significantly associated with higher odds of CAI with male clients (AOR range: 1.05–1.42, all p < 0.05). Likewise, CAI with male regular partners was more frequently reported by participants who experienced higher levels of victimization, rejection, and anxiety (AOR range: 1.37–2.88, all p < 0.05). No significant interaction effects of gender minority stress and mental health on sexual behaviors were observed. Interventions addressing the multiple psychosocial risks are warranted to prevent behavioral risks of TGSW.
Transgender hormone therapy can play an important role in patients undergoing gender affirmation and results in improved quality of life for transgender individuals. Hormone therapy may be a step on the pathway to gender-affirming surgery, but many patients may choose to remain on hormone therapy without surgery or may not have access to surgical therapy. Basic criteria should be met prior to initiation of hormone therapy. Hormone therapy in transgender women includes estrogen and anti-androgens. Transgender men are treated primarily with exogenous testosterone supplementations. Patients should be made aware of side effects of hormone therapy prior to initiation. Close monitoring is important during the first year of therapy, and it can be less frequent thereafter. Although there is no consensus available, it is generally recommended that estradiol therapy be stopped temporarily before gender affirmation surgeries or other major surgical interventions. It is less clear whether it is necessary to hold testosterone therapy prior to surgery. Usual thromboprophylaxis measures are recommended for any gender-affirming surgeries that require extensive surgery and prolonged immobilization.
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.
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.
Introduction
Transgender populations have high rates of many mental health diagnoses, but often delay or avoid mental health care due to prior poor experiences or fear of discrimination. This indicates a need for supportive and effective transgender mental health care. We aim to identify the features of such care through a systemized narrative review of the literature.
Methods
Comprehensive searches of six databases were run using index terms and keywords. Searches were limited to English language studies published from 2000 to August 2019 and followed SANRA criteria. Identified records underwent title/abstract screen for relevance and then were assessed for inclusion using predetermined criteria. Included articles were tabulated and their results synthesized with attention to areas of thematic overlap.
Results
The search returned 1928 unique articles with 35 meeting inclusion criteria and a further one article identified on bibliography screen. Articles reported a range of experiences and preferences across mental health care settings, with common themes emerging. Several reported on retention in care, satisfaction with care, helpfulness of care, or change in symptom burden after receiving care.
Discussion
We discuss preliminary features of supportive transgender mental health care, recommendations for clinical practice, gaps in the literature, and areas for future research.
Aim:
Although there is an increase in the social acceptance of the gender dysphoria (GD) population, they still suffer a high degree of emotional stress, which highlights the importance of knowing their mental illness diagnosis.
Methods:
A systematic review was conducted to identify the frequency of lifetime axis I mental disorders in this population, using MEDLINE/PubMed, SciELO, Cochrane, EMBASE, PsychINFO databases and handsearching, examining articles published after 1980. The search used the key words: ("transgender" OR "gender identity disorder" OR "gender dysphoria" OR "transsexualism" OR "gender dysphoric patients" OR "gender incongruence") AND ("mental disorder" OR "axis I" OR "psychiatric disorders") AND ("comorbidity" OR "comorbid" OR "prevalence").
Results:
From 233 papers found, 5 were included. The total sample comprised 577 individuals diagnosed with GD, of which 307 (53.2%) presented at least one mental disorder in their lifetime. Among this high frequency of Axis I disorders, mood disorders were the most frequent [found in 243 individuals (42.1%)], followed by anxiety disorders [155 (26.8%)], and substance use/abuse disorders [85 (14.7%)].
Conclusion:
This study offers important data to researchers and clinicians so they can recognize and contribute to the development of public policy on the mental health of population diagnosed with GD, which requires special attention as it contributes to their functional impairment. This article is protected by copyright. All rights reserved.
The literature on cross-dressing men has been primarily limited to self-identified patients at psychiatric clinics who are in distress. To understand the personality trait characteristics and sexual functioning of nonpatient cross-dressers, 188 non-treatment-seeking male cross-dressers completed the NEO Personality Inventory (NEO-PI) and the Derogatis Sexual Functioning Inventory (DSFI). Respondents were classified as transvestites (TV; N = 83), transgenderists (TG; N = 61), or transsexuals (TS; N = 44) based on self-report and the nature of their cross-gender activities (e.g., use of female hormones, desire for sex reassignment, and amount of time spent in female role). These diagnostic groups did not differ on the five broad personality domains of the NEO-PI, but TS men scored higher than TV and TG men on the Aesthetics facet scale of Openness to Experience (O). In terms of the DSFI scales, TS men reported lower sexual drive than TV and TG men, and TS and TG men exhibited greater psychiatric symptoms and feminine gender role, and poorer body image than TV men. Upon exclusion of a group of 49 respondents who previously sought treatment for psychological problems, no significant differences emerged among the three diagnostic groups on the NEO-PI domain and facet scales. Consideration of the DSFI scales showed that TS men experienced less sexual drive, more psychiatric symptoms, and a greater feminine gender role than TV or TG men. This study suggests that cross-dressers not seen for clinical reasons are virtually indistinguishable from non-cross-dressing men using a measure of personality traits, a sexual functioning inventory, and measures of psychological distress. These results emphasize the importance of using clinical significance criteria as required by DSM-IV guidelines before diagnosing men who cross-dress with an axis I disorder.
(C) Williams & Wilkins 1996. All Rights Reserved.
This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States.
The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview.
Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status.
The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.
The Rorschach Comprehensive System was used to assess postoperative psychological functioning in transsexuals who applied for sex reassignment in adolescence. We investigated a group of 22 consecutive adolescent transsexuals, who were otherwise psychologically well adapted. Nineteen subjects provided valid Rorschach protocols before and after sex reassignment. The most notable change found was an increase in X + %, reflecting a decrease in both distorted perception and idiosyncratic perception. Little support was found for the idea of major psychological deterioration for the patients as a group. Rather, the results suggest stability in psychological functioning over time. The Rorschach findings are consistent with questionnaire data from earlier studies, with the exception that the Rorschach data may point to some improvement in reality testing.
Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.
The public health problem-solving paradigm is a comprehensive method not previously applied to preventive interventions for personality disorder.
To present an overview for clinical psychiatrists.
Review of epidemiological research into DSM-IV Axis Il disorders and application to the paradigm.
Personality disorder affects a substantial proportion of the population. Burdens on health care, social and criminal justice agencies have yet to be accurately quantified. Debates continue over case definition, but there is increasing information on prevalence using 'broad' definitions and aetiology. A conceptual framework, based on development, suggests preventive interventions should be targeted in childhood. The public health approach also requires monitoring of risk factors operating at the population level.
Services in England and Wales for persons with personality disorder are currently inadequate. The problem-solving paradigm suggests new preventive interventions. Psychiatrists should renegotiate their relationship with policy-makers and reconsider their preventive role.
From data collected within the frame of a longitudinal epidemiologic study of a representative sample population of young adults (the Zurich Study), anxiety disorders—anxiety and phobic states—were analyzed. The current prevalence rate was found to be 2.9% for anxiety states and 4.3% for phobic states, totaling 7.2%. Because of their anxiety disorders, one-fifth of the cases had undergone treatment during the preceding 12 months.
Substantial difficulties arose, from the point of view of classification. The currently used categories, such as anxiety states, panic attacks, agoraphobia, simple phobia, social phobia, have more in common than differing symptoms. On a syndromal level, numerous overlapping configurations resulted which can only be artificially forced into the aforementioned diagnostic classes of anxiety disorders. On the symptom level, merely a few operationalized items defined these categories. In this way, most of a broad identical ‘nonspecific’ symptomatology was not taken into account. This was exemplified by a comparison of anxiety states and agoraphobia. In fact, these two groups did not differ significantly in many symptoms or in SCL-90 profiles, but did show a highly significant difference from control samples. Both groups suffered to the same great degree from depressive, cardiovascular, and gastrointestinal symptoms.
We doubt whether any forced categorical diagnostic differentiation of anxiety and phobic states is at all reasonable.
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
From data collected within the frame of a longitudinal epidemiologic study of a representative sample population of young adults (the Zurich Study), anxiety disorders--anxiety and phobic states--were analyzed. The current prevalence rate was found to be 2.9% for anxiety states and 4.3% for phobic states, totaling 7.2%. Because of their anxiety disorders, one-fifth of the cases had undergone treatment during the preceding 12 months. Substantial difficulties arose, from the point of view of classification. The currently used categories, such as anxiety states, panic attacks, agoraphobia, simple phobia, social phobia, have more in common than differing symptoms. On a syndromal level, numerous overlapping configurations resulted which can only be artificially forced into the aforementioned diagnostic classes of anxiety disorders. On the symptom level, merely a few operationalized items defined these categories. In this way, most of a broad identical 'nonspecific' symptomatology was not taken into account. This was exemplified by a comparison of anxiety states and agoraphobia. In fact, these two groups did not differ significantly in many symptoms or in SCL-90 profiles, but did show a highly significant difference from control samples. Both groups suffered to the same great degree from depressive, cardiovascular, and gastrointestinal symptoms. We doubt whether any forced categorical diagnostic differentiation of anxiety and phobic states is at all reasonable.
The psychological functioning of male heterosexuals, transvestites, preoperative transsexuals and postoperative transsexuals was assessed. The groups represented a gradient of progressive feminization which showed progressive levels of psychological dysfunction. The data indicated that the transsexuals studied were indicative of a select group demonstrating profound psychological dysfunction. The study contributes to the recent literature, which indicates that sex reassignment surgery for this group is not the treatment of choice. Criteria for projecting postoperative outcome are outlined which can be utilized to direct gender dysphoria patients to alternate treatments.
This paper critically reviews over 30 years of psychological testing of transsexualism, during which time 41 studies have been published. A review of the psychological tests and methodology employed, the search for an adequate control group, and an analysis of the findings are presented. It is argued that we have reached a critical point in transsexual research. Researchers must reconsider the "hit or miss" approach to psychological testing with transsexuals and relate psychological testing to the actual clinical phenomenon of transsexualism; addressing the newer conceptualizations of transsexualism as a variant of borderline pathology.
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
A group of transsexuals, 9 biological men and 10 women, was assessed according to clinical DSM-III-R diagnosis and a self-report instrument for Axis II diagnoses based on the Structured Clinical Interview for DSM-III-R (SCID screen). A control group of 133 individuals was assessed by the same instrument. Combined with a functional criterion according to the Global Assessment of Functioning, the SCID screen showed good agreement with clinical Axis II diagnoses. The overall proportion of Axis II criteria fulfilled, proportion of criteria fulfilled for every single personality disorder and number of personality disorders were calculated from the modified version of the SCID screen. Personality disorders, mainly within cluster B, were identified among 5 of 19 transsexuals, and a majority had multiple personality disorders. Among controls, no personality disorder was identified. Personality traits as measured by the SCID screen revealed significantly more subthreshold pathology among transsexuals than controls in 8 of 12 personality categories. The proportion of overall Axis II criteria fulfilled was 29% among transsexuals versus 17% among controls. Sex differences among transsexuals, the usefulness of the SCID screen and diagnostic problems in DSM-III-R with respect to gender identity disorders are discussed.
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.
From the Zurich cohort study (n = 591), the association of major depressive episodes and recurrent brief depression (RBD) with other psychiatric disorders is presented cross-sectionally at age 28 and 30 years, and over ten years (age 20 to 30 years). Longitudinally, the odds ratios of major depression are highest with dysthymia (4.4), generalised anxiety disorder (4.4), panic disorder (2.7), hypomania and agoraphobia (2.6), and social phobia (2.4). There is a significant association with cannabis consumption and smoking. Follow-up data over nine years are available for 41 patients with a major depressive disorder (MDD) and 62 with RBD: approximately 20% of MDD patients did not receive a diagnosis during follow-up. Major depression reoccurred in 32%, became bipolar in 24%, or developed into RBD in 24%. RBD remitted in 41%, reoccurred in 35%, turned into major depression in 22%, and became bipolar in only 7%. Longitudinally, MDD and RBD show a symmetrical diagnostic change in a quarter of the cases. There is no substantial development of MDD or RBD into minor depression or generalised anxiety disorder. Thirteen per cent of those with RBD later developed panic disorder.
Previous studies suggest that many transsexuals evidence an Axis I diagnosis according to the DSM-IV classification (e.g., psychoses, major affective disorder). The current study examined retrospectively the comorbidity between gender dysphoria and major psychopathology, evaluating the charts of 435 gender dysphoric individuals (318 male and 117 female). All had undergone an extensive evaluation, addressing such areas as hormonal/surgical treatment, and histories of substance abuse, mental illness, genital mutilation, and suicide attempts. In addition, a subgroup of 137 individuals completed the MMPI. Findings revealed over two thirds were undergoing hormone reassignment, suggesting a commitment to the real-life cross-gender process. One quarter had had problems with substance abuse prior to entering treatment, but less than 10% evidenced problems associated with mental illness, genital mutilation, or suicide attempts. Those completing the MMPI (93 female and 44 male) demonstrated profiles that were notably free of psychopathology (e.g., Axis I or Axis II criteria). The one scale where significant differences were observed was the Mf scale, and this held true only for the male-to-female group. Psychological profiles as measured by the MMPI were more "normal" in the desired sex than the anatomic sex. Results support the view that transsexualism is usually an isolated diagnosis and not part of any general psychopathological disorder.
More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.
Gender dysphoric patients of transsexual type (TS) have been considered to have severe psychopathology. However, these notions have a weak empirical documentation.
TS patients (n = 86), patients with personality disorder (PD, n = 98) and adult healthy controls (HC, n = 1068) were compared by means of the Symptom Checklist 90 (SCL-90). All patients were diagnosed by structured interviews (Axis I, II and V of DSM-III-R/IV). PD patients were further characterized according to the LEAD-standard.
TS patients scored significantly lower than PD patients on the Global Symptom Index and all SCL-90 subscales. Although the TS group generally scored slightly higher than the HC group, all scores were within the normal range.
TS patients selected for sex reassignment showed a relatively low level of self-rated psychopathology before and after treatment. This finding casts doubt on the view that transsexualism is a severe mental disorder.
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