References 4.b: Transsexualism is not a mental illness

This chapter requires some clarification. After all, transsexualism causes real, psychological suffering. There is no doubt that transsexuals are more affected by certain mental problems than the general population. Transsexuals have higher than average incidence rates of depressive and anxiety disorders (so called mood, affective or axis 1 disorders), which can cause some functional impairment, including impeding stable relationships and friendships. This is to be expected, as the definition of transsexualism usually involves a reduction in the quality of life (figuratively put, gender dysphoria is a feeling of depression mixed with anxiety, like the sense of being lost on the wrong road). It is exactly this pain felt by transsexuals that motivates them to make changes to their lives.

One of the questions is about first causes. Does gender dysphoria develop from psychopathological disorders, or are the psychological difficulties caused by the reaction of the social environment to the transsexual? The data indicates the latter is the case. This is well put by Sarah Seton: “Contrary to current belief, transsexuals are not tormented by their condition: it is their condition, which prompts society to torment them.”

How can we be confident about this?

First of all, by means of comparing different groups of transsexuals, or transsexuals at different stages of their life: Medical treatment such as hormone therapy and surgery reduces mental problems suffered by transsexuals. Being out socially, living in the desired gender role, reduces mental problems. Female-to-male transsexuals, who encounter on average less social resistance and blend into their desired gender role more easily than male-to-female transsexuals, have fewer mental problems. Children and adolescent transsexuals, early transitioners, have fewer mental problems than adult transsexuals. Mental problems associated with gender dysphoria, even the gender dysphoria itself, can be healed by treating the gender mismatch.

Secondly, by looking at the type of mental problems. More serious types of mental problems, such as developmental and personality disorders (axis 2 disorders) are not found in high rates among transsexuals. Developmental disorders include autism and mental retardation, disorders which are typically first evident in childhood. Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world.  They include Paranoid, Antisocial, and Borderline Personality Disorders. It is often the case that milder disorders, such mood disorders (depression, anxiety) are caused by developmental or personality disorders. Gender dysphoria neither seems to be caused by these serious, life-long types of mental problems, nor does it seem to be related to them.

Thirdly, by looking at the severity of the mental problems encountered. Mental issues can be divided into more serious clinical and less problematic subclinical disorders. Transsexuals suffering from mental problems do not have high incidence rates of clinical disorders.

Transsexuals face a difficult reality, often with rejection by parents, family and friends, marked by hate of their own bodies, difficulties in social and occupational life. Often, their childhood and adolescence was not a happy one, ruined by bullying and social stigma. These factors need to be taken into account when assessing the psychological health of transsexuals.

The psychological findings, as summarised above, and as detailed below, are indeed remarkable. It seems that transsexuals have a healthy brain in a healthy body, both within normal, subclinical standards of ailments. It is the mismatch between the gender of the brain and the sex characteristics of the body/the assigned gender at birth that causes gender dysphoria.

Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis

This study is the third in a series to examine behavioral and emotional problems in children and adolescents with gender dysphoria in a comparative analysis between two clinics in Toronto, Ontario, Canada and Amsterdam, the Netherlands. In the present study, we report Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) data on adolescents assessed in the Toronto clinic (n = 177) and the Amsterdam clinic (n = 139). On the CBCL and the YSR, we found that the percentage of adolescents with clinical range behavioral and emotional problems was higher when compared to the non-referred standardization samples but similar to the referred adolescents. On both the CBCL and the YSR, the Toronto adolescents had a significantly higher Total Problem score than the Amsterdam adolescents. Like our earlier studies of CBCL data of children and Teacher’s Report Form data of children and adolescents, a measure of poor peer relations was the strongest predictor of CBCL and YSR behavioral and emotional problems in gender dysphoric adolescents.

Author/-s:       Annelou L. C. de Vries; Thomas D. Steensma; Peggy T. Cohen-Kettenis; Doug P. VanderLaan; Kenneth J. Zucker

Publication:     European Child & Adolescent Psychiatry, 2015

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Sociodemographic Characteristics and Psychological Adjustment Among Transsexuals in Spain

This study examined the sociodemographic characteristics and the psychological adjustment of transsexuals in Andalusia (Spain), and also analyzed the differences between female-to-male (FtM) and male-to-female (MtF) transsexuals. The sample included 197 transsexuals (101 MtF and 96 FtM) selected from those who visited the Transsexual and Gender Identity Unit at the Carlos Haya Hospital in Malaga between 2011 and 2012. Our analyses indicated that MtF transsexuals were more likely to have lower educational levels, live alone, have worked less frequently throughout their lifetime, and have engaged in prostitution. For FtM transsexuals, there were more frequent references to the mother’s psychiatric history and more social avoidance and distress. Multivariate analysis showed that the number of personality dysfunctional traits and unemployment status were associated with depression in the entire sample. The following three conclusions can be made: there are significant differences between MtF and FtM transsexuals (mainly related to sociodemographic variables), depression was high in both groups, and a remarkable percentage of transsexuals have attempted suicide (22.8 %) or have had suicidal thoughts (52.3 %).

Author/-s:       José Guzmán-Parra; Nicolás Sánchez-Álvarez; Yolanda de Diego-Otero; Lucía Pérez-Costillas; Isabel Esteva de Antonio; Miriam Navais-Barranco, Serafina Castro-Zamudio; Trinidad Bergero-Miguel

Publication:     Archives of Sexual Behavior, 2015

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Stigmatization and Mental Health in a Diverse Sample of Transgender Women

Purpose: Previous research indicates elevated risk for psychological distress in sexual and gender minority populations, and some research suggests that stigma contributes to elevated psychological distress among members of these groups. This study examined the hypothesis that exposure to transgender-related stigma (TRS) is associated with both higher levels of depression and anxiety among transgender women.

Methods: We analyzed data from a diverse sample of 191 adult transgender women living or working in the San Francisco Bay area who were recruited using purposive sampling methods to participate in a cross-sectional survey, which included measures of stigmatization, depression, and anxiety.

Results: Higher levels of exposure to TRS were independently associated with higher levels of depression (β=0.31, P<.001) and anxiety (β=39, P<.001), adjusting for self-reported health and sociodemographic co-variates. Associations between stigmatization, depression, and anxiety were not moderated by participants' age or race/ethnicity.

Conclusion: Findings suggest a need for counseling interventions to address the role of stigmatization as a factor potentially contributing to psychological distress among transgender women. This research further highlights the need to develop a stronger evidence base on effective counseling approaches to improve the mental health of transgender women.

Author/-s:       Mei-Fen Yang; David Manning; Jacob J. van den Berg, Don Operario

Publication:     LGBT Health, 2015

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Disorders of gender identity: what to do and who should do it?

Transsexualism is not usually indicative of psychopathology. In carefully selected individuals, with multidisciplinary support, a change of social gender role and cross-sex hormone treatment greatly improves the psychological and social state. Sustained improvement merits gender reassignment surgery. The key is early referral with subsequent primary care cooperation in the treatment plan.

Author/-s:       James Barrett

Publication:     The British Journal of Psychiatry, 2014

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

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors.

Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors.

Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 (SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05.

Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt.

Results: A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre- and postoperative assessments.

Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Author/-s:       Gunter Heylens; Charlotte Verroken; Sanne De Cock; Guy T’Sjoen; Griet de Cuypere

Publication:     The Journal of Sexual Medicine, 2014

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Family Rejection, Social Isolation, and Loneliness as Predictors of Negative Health Outcomes (Depression, Suicidal Ideation, and Sexual Risk Behavior) Among Thai Male-to-Female Transgender Adolescents

This study examined the influence of family rejection, social isolation, and loneliness on negative health outcomes among Thai male-to-female transgender adolescents. The sample consisted of 260 male respondents, of whom 129 (49.6 %) were self-identified as transgender and 131 (50.4 %) were self-identified as cisgender (nontransgender). Initial multivariate analysis of variance indicated that the transgender respondents, when compared to the cisgender respondents, reported significantly higher family rejection, lower social support, higher loneliness, higher depression, lower protective factors (PANSI-positive) and higher negative risk factors (PANSI-negative) related to suicidal behavior, and were less certain in avoiding sexual risk behaviors. Multiple regression analysis indicated that the exogenous variables of family rejection, social isolation, and loneliness were significant predictors of both transgender and cisgender adolescents’ reported levels of depression, suicidal thinking, and sexual risk behaviors. The implications of these findings are discussed.

Author/-s:       Mohammadrasool Yadegarfard; Mallika E. Meinhold-Bergmann; Robert Ho

Publication:     Journal of LGBT Youth, 2014

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Perfil psicológico de personas transexuales en tratamiento

Introduction: Transsexualism is an emergent field in healthcare and consequently is plagued by stereotypes. Two of the most widespread misconceptions are that transgender people have serious psychopathological disorders and that they are less happy than the general population.

Objective: The main aim of this study was to characterize the psychological profile of transgender people and, in particular, the presence of psychopathological features in their personality profile. The presence of depressive features was also investigated. A second aim was to assess the differences in psychological profile between the sexes (female-to-male or male-to-females transgender people).

Material and Method: A cross-sectional study was carried out. The patients were selected consecutively according to their order of access to the Gender Identity Disorder Unit (GIDU) of Madrid at the beginning of the study. The sample was composed of 121 patients from the GIDU. All patients completed the study. The access criterion was a diagnosis of transsexualism. The patients were administered the following psychological tests: Gender Identity Diagnosis Interview, the General Health Questionnaire (GHQ-28), Emotional Competence Questionnaire, Psychological well-being Scale, Life Satisfaction Scale, Subjective Happiness Scale, the NEO Personality Inventory (NEO-PI) and the Millon Clinical Multiaxial Inventory-III (MCMI-III).

Outcomes: The subjects showed a high level of well-being. No serious psychopathological alterations were found. Differences between sexes were few but striking. Only one significant factor was found in the subjects’ personality profile.

Conclusions: Transgender people do not have a psychopathological personality profile. The differences between sexes are few but important.

Author/-s:       José Miguel Rodríguez-Molina; Lara Pacheco-Cuevas; Núria Asenjo-Araque; Núria García-Cedenilla; María Jesús Lucio-Pérez; Antonio Becerra-Fernández

Publication:     Revista Internacional de Andrología, 2014

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Psychosocial Adjustment to Sex Reassignment Surgery: A Qualitative Examination and Personal Experiences of Six Transsexual Persons in Croatia

In Croatia, transgender individuals face numerous social and medical obstacles throughout the process of transition. The aim of this study was to depict the factors contributing to the psychosocial adjustment of six transsexual individuals living in Croatia following sex reassignment surgery (SRS). A combination of quantitative and qualitative self-report methods was used. Due to the specificity of the sample, the data were collected online. Standardized questionnaires were used to assess mental health and quality of life alongside a series of open-ended questions divided into 4 themes: the decision-making process regarding SRS; social and medical support during the SRS process; experience of discrimination and stigmatizing behaviors; psychosocial adjustment after SRS. Despite the unfavorable circumstances in Croatian society, participants demonstrated stable mental, social, and professional functioning, as well as a relative resilience to minority stress. Results also reveal the role of pretransition factors such as high socioeconomic status, good premorbid functioning, and high motivation for SRS in successful psychosocial adjustment. During and after transition, participants reported experiencing good social support and satisfaction with the surgical treatment and outcomes. Any difficulties reported by participants are related to either sexual relationships or internalized transphobia. The results also demonstrate the potentially protective role that a lengthier process of transition plays in countries such as Croatia.

Author/-s:       Nataša Jokić-Begić; Anita Lauri Korajlija; Tanja Jurin

Publication:     The scientific world journal, 2014

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Substance Use and Social Anxiety in Transsexual Individuals

Objective: This study examined social anxiety and use of cannabis and cocaine among transsexuals.

Methods: A total of 379 transsexuals seeking treatment or consultation participated in this study, providing data on sociodemographics, substance use, and anxiety. Analyses were based on (a) lifetime but not current use versus never used and (b) current use only versus no current use (lifetime only or never used).

Results: Lifetime only cannabis users (n = 72; 19 %) and lifetime only cocaine users (n = 36; 9.8 %) were older, had more victimization, and received more mental health treatment that those who never used. Current cannabis users (n = 47; 12.4 %) had higher scores on fear of negative evaluation and social avoidance than those not currently using (p <0.01). Multivariate analysis showed that social avoidance and fear of negative evaluation were associated with current cannabis use (p <0.05), but not cocaine. Further, being single was associated with current cannabis use, after controlling for social avoidance and fear of negative evaluation (p <0.05).

Conclusions: Transsexuals’ levels of anxiety and cannabis/cocaine use are comparable to those in the general population. Cannabis may be used to control anxiety and can have detrimental clinical implications for transsexuals.

Author/-s:       Jose Guzman-Parra; Pedro Paulino-Matos; Yolanda de Diego-Otero; Lucia Perez-Costillas; Amelia Villena-Jimena; Maria A. Garcia-Encinas; Trinidad Bergero-Miguel

Publication:     Journal of dual diagnosis, 2014

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

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

Author/-s:       Marco Colizzi; Rosalia Costa; Orlando Todarello

Publication:     Psychoneuroendocrinology, 2014

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1490 – Transsexualism and personality, study about 14 cases with structured assessment

Introduction: Transsexualism is a rare condition, characterized by permanent conviction of belonging to opposite sex, leading to a request for hormono-surgical sex reassignment.

Objectives and aims of the study: The personality of transsexual patient is a matter of debate: most psychoanalysts postulate a severe personality disorder, while STOLLER’s and biological hypothesis argue for of the absence of specific disturbance.

Methods: Fourteen transsexuals patients (9 men and 5 women), referred to the specialized multidisciplinary team of Nantes University hospital were included. All received hormone therapy, 5 patients underwent surgery. The MMPI-2 and SCID-II were used as standardized tools to assess personality.

Results: Using the SCID-II, frequency of personality disorders was 14.29%, showing no statistical difference compared to the general population (10%). The MMPI-2 mean T score was close to the general population 50. Moreover, man versus woman transsexuals have a degree of psychopathology significantly higher than woman versus man transsexuals. Operated versus non-operated patients showed no significant differences in the various tests.

Conclusion: Our results tend to relativize the unique psychopathological determinism of transsexualism, and seem to strengthen the hypothesis of biological factors involved in this problem. The prognosis is more favorable for woman versus man transsexuals.

Author/-s:       V. Gaudeau

Publication:     European Psychiatry, 2013

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Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study

Objective: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.

Method: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.

Results: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.

Conclusion: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.

Author/-s:       Thomas Dirk Steensma; Jenifer K. McGuire; Baudewijntje P. C. Kreukels; Anneke J. Beekman; Peggy T. Cohen-Kettenis

Publication:     Journal of the American Academy of Child and Adolescent Psychiatry, 2013

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From Gender Variance to Gender Dysphoria: Psychosexual development of gender atypical children and adolescents

Summary: Children may show variability in their gender role behaviors, interests and preferences and/or their experienced gender identity (their experience to be male, female or a different gender). Within the male-female continuum of gender role expressions and gender identity three groups can be distinguished. First, the gender normative children: Their gender role and gender identity are congruent with their natal sex. Second, the gender variant children: These children show (mild) cross-gender behaviors, interests and preferences, and may experience a gender identity which is congruent with their natal sex to a lesser extent than is the case in gender normative children. And third, the gender dysphoric children: These children show extreme and enduring forms of cross-gender role expressions, experience a cross-gender identity and fulfill the criteria of a DSM-IV-TR diagnosis of Gender Identity Disorder (GID) (American Psychiatric Association 2000). In contrast to most of the gender variant children, gender dysphoric children may need clinical attention as a result of significant distress or a significant risk of distress, and/or impairment in important areas of functioning. Knowledge about the future development, the trajectories and possible associated factors of gender non-normative children (both gender variant and genderdysphoric) is however limited.
The studies described in this thesis aimed to enhance our understanding of the development of gender variant and gender dysphoric children and adolescents, and to identify factors associated with the persistence and desistence of gender dysphoria.

In chapter 2, we provided an overview of what is currently known about the trajectories and contributing factors to gender identity development, particularly during adolescence in the general population and in gender variant/gender dysphoric youth. Compared to what is known from gender identity development in gender variant or gender dysphoric children, studies of normative gender identity development during adolescence in the general population are lacking behind.

With regard to the factors contributing to non-normative gender identity development, earlier studies mainly focused on the role of psychosocial factors. Factors such as elevated levels of psychopathology in the parents, increased anxiety of the child, and a lack of parental limit setting have been put forward as possible determinants. However, the evidence from these studies showed to be equivocal and it is unclear whether the factors that were associated with a non-normative gender identity development were the cause of this development or a consequence of the gender variance or gender dysphoria. More recently, research has focused on the role of biological factors on a non-normative gender identity development. Studies of individuals with a Disorder of Sex Development (DSD), congenital condi- tions in which the development of chromosomal, gonadal and/or anatomical sex is atypical (Hughes et al. 2006), point to the role of prenatal exposure to gonadal hormones and their effects on gender role behavior and possibly on gender identity development. From post mortem, neuropsychological, and brain imaging studies of individuals with gender dysphoria, differences between gender dysphoric individuals and members of their natal sex have been found. However, these differences were not found for all measures and the direction of the differences is not always consistent or not yet sufficient to form a basis for a broad theory on gender identity development. The current evidence makes clear that there is no simple relationship between psychological and social factors and gender identity development, and brain development and the development of gender identity. In addition to this, although several researchers have acknowledged that nature and nurture interact, they have not tried to integrate both aspects in their studies thus far.

As for the future development of gender dysphoric children, our overview of the literature indicated that gender identity in childhood seems more malleable than later in adolescence or in adulthood. Furthermore, we described that adolescence is a crucial period for the consolidation of gender identity and persistence of gender dysphoria. We discussed that the onset of physical puberty in this period may steer this process, but that there are also indications that cognitive aspects of gender identity (e.g. confusion and ambivalence with ones gender identity) has its own influence. For those without a history of childhood gender dysphoria, adolescence may initiate gender dysphoria. Regardless of the various developmental trajectories of a non-normative gender identity development, adolescence can be denoted as a crucial developmental period for gender identity.

In chapter 3 we reported on a study where we validated a 12-item dimensional scale that aims to measure gender dysphoria, in a sample of 1119 adolescents and adults (M age 24.6, range 12–75). The male (UGDS-M) and female (UGDS-F) versions of the Utrecht Gender Dysphoria Scale (UGDS) were assessed in a group of participants diagnosed with a GID (N=545), a group who was subthreshold for GID (N=103), participants with a DSD (N=60), and non-transgender heterosexual (N=219), gay/lesbian (N=150), and bisexual (N=42) controls. Both versions of the UGDS appeared to be reliable scales with a strong ability to discriminate between clinically referred gender dysphoric individuals and non-clinically referred controls and DSD participants. Sensitivity was 88.3 % (UGDS-M) and 98.5 % (UGDS-F), specificity was 99.5 % (UGDS-M) and 97.9 % (UGDS-F). Comparison of the mean total scores showed that there was significantly more gender dysphoria in participants diagnosed with a GID, compared to participants who were subthreshold for GID, for both versions. The two transgender groups showed significantly more gender dysphoria than the DSD and control participants. We concluded from our findings that these qualities make the instrument useful for clinical and research purposes.

Chapter 4 reported on a 24 years longitudinal study where we examined whether childhood gender variance was associated with the report of a bi- or homosexual sexual orientation and gender discomfort in adulthood in the general population. In a sample of 406 boys and 473 girls we measured gender variance in childhood (M age 7.5, range 4–11) and sexual orientation and gender dysphoria in adulthood (M age 30.9, range  27–36). Our findings showed that the intensity and presence of childhood gender variance was higher in girls than in boys, and that gender variance was reported more frequently in younger children than in older children. Furthermore, we found that the presence of childhood gender variance was associated with the presence of a homosexual orientation in adulthood, but not with bisexuality. The chance of a homosexual orientation in sexual attraction, sexual fantasy, sexual behavior, and sexual identity were 8 to 15 times higher for both male and female participants with a history of gender variance as reported by the parents (10.2 % to12.2 %), compared to participants without a history of gender variance (1.2 % to 1.7 %). The presence of childhood gender variance was not significantly associated with gender discomfort/gender dysphoria in adulthood. We concluded in this study that childhood gender variance, at least as measured by the Child Behavior Checklist (CBCL), is not predictive for a gender dysphoric outcome in adulthood in the general population. Furthermore, the presence of childhood gender variance and a homosexual sexual orientation in adulthood are associated in the general population, but this association is much weaker than in clinically referred gender dysphoric children.

Chapter 5 described the findings from a qualitative study where we tried to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. We interviewed 25 adolescents (M age 15.9, range 14–18), who were diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood (M age 9.4, range 6–12). Our findings on possible predictors in childhood for the different trajectories showed that the 14 persisters and 11 desisters reported quite similar childhood experiences, but subtle differences in their experience of gender and the labelling of their feelings were observed.

As for underlying mechanisms and experiences that may have steered the persistence and desistence of gender dysphoria, we identified the period between the ages of 10 and 13 to be crucial. In the perceptions of the adolescents, three factors were related in this period to the intensification of gender dysphoria in persisters or remittance of gender dysphoric feelings in the desisters; (1) the changing social environment, where the social distance between boys and girls gradually increases, (2) the anticipation of, and actual body changes during puberty, and (3) the experience of falling in love, sexual attraction and sexual experiences. Interestingly, even in this relatively small sample of adolescents, we observed that the feelings of gender dysphoria did not completely remit in all desisters. Furthermore, our observation of high reports of sexual orientations and sexual attractions directed towards individuals of the same natal sex seemed to be in concordance with the earlier findings from the prospective quantitative literature on gender dysphoric children. Finally, the stories of the persisters and desisters on the effect of social role transitioning (in appearance and/or a name change or pronoun change) revealed that transitioning was experienced as a relief in persisters, but could result in a troublesome process of changing back to their original gender for desisters.

Chapter 6 reported on a quantitative follow-up study that examined the factors associated with the persistence and desistence of childhood gender dysphoria, and adolescent feelings of gender dysphoria and sexual orientation. In a sample of 127 adolescents (79 boys, 48 girls), who were referred for gender dysphoria in childhood (age range 6–12) and followed up in adolescence (age range 15–19), we observed a persistence rate of 37 % (47 persisters out of the 127 adolescents). We examined childhood differences among persisters (N=47) and desisters (N=80) in demographics, developmental background, childhood psychological functioning, the quality of peer relations and childhood gender dysphoria, and adolescent reports of gender dysphoria, body image and sexual orientation. Our findings showed that persisters reported higher intensities of gender dysphoria, more body dissatisfaction and higher reports of a same natal-sex sexual orientation, compared to the desisters, and were in line with earlier findings from prospective follow-up studies in clinical populations.
As for the factors associated with the persistence of gender dysphoria, we found that a higher intensity of childhood gender dysphoria (through self- and parental report, and through cognitive and/or affective gender identity responses), an older age at referral, and transitioning (at least partially) to the preferred gender role were predictive of childhood gender dysphoria persistence.
In addition to this, we found that the chance of persisting was higher in natal gender dysphoric girls than in boys, but that factors such as psychological functioning, the quality of peer relations, demographic (e.g. family structure, parents’ social economic class), and developmental background (e.g. birth weight, pregnancy duration) were not associated with the persistence of childhood gender dysphoria. Finally, our findings showed that the factors associated with the persistence of gender dysphoria were different for the two natal sexes. For natal boys, the age at referral, the gender role presentation, the self report of a cross-gender identification (“I am a boy” or “I am a girl”), and the parental report of the intensity of gender role behavior showed to be the major predictive factors for the persistence of gender dysphoria, whereas for girls, the self reported cross-gender identification and the intensity of gender dysphoria turned out to have a higher predictive value than the other evaluated factors.

Chapter 7 presented a communication where we addressed the topic of social transitioning in gender dysphoric children in early childhood. We reported on our observation of increasing numbers in our clinical population of children who completely (change in clothing and hair style, first name, and use of pronouns) or partially (change in clothing and hair style, but did not have a name and pronoun change) transitioned between the period of the year 2000 and 2009.

Before the year 2000, 2 prepubertal boys, out of 112 referred children to our clinic, were living completely in the female gender role. Between 2000 and 2004, 3.3 % (4 out of 121 children) had completely transitioned, and 19 % (23 out of 121 children) were partially transitioned when they were referred. In the period between 2005 and 2009 we observed that 8.9 % (16 out of 180 children) completely transitioned and 33.3 % (60 out of 180 children) partially transitioned at the time of referral.

In discussing the increasing rates of socially transitioned gender dysphoric children we noted that follow-up studies show that the persistence rate of childhood gender dysphoria is about 15.8 %, and wondered what would happen to children who transitioned in childhood, but turned out to be desisters. We referred to two cases of natal girls, who transitioned early in childhood and for whom the gender dysphoria desisted. Their process of changing back to their original gender was reported to be a troublesome process (Chapter 5 and Steensma et al. 2011). We concluded that it is advisable to be very careful when taking steps regarding social transitioning during the early childhood years, as they might be difficult to reverse.

In chapter 8 we described a cross-national investigation that examined the psychological functioning and the quality of peer relations between gender dysphoric youth from Toronto, Canada and Amsterdam, the Netherlands. In a sample of 544 children and 174 adolescents, referred to the specialized gender identity clinics in both countries, we assessed the Teacher’s Report Form to measure emotional and behavioral problems, the quality of peer relations and gender dysphoria. Our findings in both countries showed that the children were, on average, better functioning than the adolescents, and that the gender dysphoric boys showed to have poorer peer relations and more internalizing than externalizing problems compared to the gender dysphoric girls. As for the degree of behavioral problems in both countries, the quality of peer relations showed to be the strongest predictor. In discussing our findings we concluded that gender dysphoric children and adolescents showed the same pattern of emotional and behavioral problems in both countries, although there were significant differences in the prevalence of problems.

Between the two countries, we found clear differences: Both the children and the adolescents from Canada had more emotional and behavioral problems and a poorer quality of peer relations than the children and adolescents from the Netherlands. In line with previous comparisons of gender dysphoric children from the two countries, we found that children and adolescents from the Netherlands presented with significantly more cross-gender behavior than those from Canada. The differences between the two countries seemed to be an effect of a poorer quality of peer relations in Canada, compared to the Netherlands. We hypothesized that this may be the result of a difference in social tolerance towards gender variant expressions, as cross-cultural studies indicate that the Netherlands is much more tolerant towards homosexuality, and most likely also towards gender variance, than most countries in the world (Veenhoven 2005).

Author/-s:       Thomas Dirk Steensma

Publication:     Dissertation, Vrije Universiteit Amsterdam, 2013

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Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness

Introduction: Subjects with gender identity disorder (GID) have been reported to be highly dissatisfied with their body, and it has been suggested that the body is their primary source of suffering.

Aims: To evaluate quality and intensity of body uneasiness in GID subjects, comparing them with a sample of eating disorder patients and a control group. To detect similarities and differences between subgroups of GID subjects, on the basis of genotypic sex and transitional stage.

Methods: Fifty male-to-female (MtF) GID (25 without and 25 with genital reassignment surgery performed), 50 female-to-male (FtM) GID (28 without and 22 with genital reassignment surgery performed), 88 eating disorder subjects (26 anorexia nervosa, 26 bulimia nervosa, and 36 binge eating disorder), and 107 healthy subjects were evaluated.

Main outcome measures: Subjects were studied by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Symptom Checklist (SCL-90), and the Body Uneasiness Test (BUT).

Results: GID and controls reported lower psychiatric comorbidity and lower SCL-90 General Severity Index (GSI) scores than eating disorder subjects. GID MtF without genital reassignment surgery showed the highest BUT values, whereas GID FtM without genital reassignment surgery and eating disorder subjects showed higher values compared with both GID MtF and FtM who underwent genital reassignment surgery and controls. Considering BUT subscales, a different pattern of body uneasiness was observed in GID and eating disorder subjects. GID MtF and FtM without genital reassignment surgery showed the highest BUT GSI/SCL-90 GSI ratio compared with all the eating disorder groups.

Conclusions: GID and eating disorders are characterized by a severe body uneasiness, which represents the core of distress in both conditions. Different dimensions of body uneasiness seem to be involved in GID subsamples, depending on reassignment stage and genotypic sex. In eating disorder subjects body uneasiness is primarily linked to general psychopathology, whereas in GID such a relationship is lacking.

Author/-s:       Elisa Bandini; Alessandra D. Fisher; G. Castellini; C. lo Sauro; L. Lelli; M. C. Meriggiola; H. Casale; L. Benni; N. Ferruccio; C. Faravelli; D. Dettore; M. Maggi; V. Ricca

Publication:     The journal of sexual medicine, 2013

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Internalizing and Externalizing Behaviors in a Group of Young People with Gender Dysphoria

The aim of the current paper was to examine externalizing and internalizing behaviors in adolescents with gender dysphoria. One hundred forty-one young people (84 natal females and 57 natal males, M age = 15.13, SD = 1.70) attending the Gender Identity Development Service in London completed the Youth Self Report form at the end of the assessment period (4 to 6 sessions). The main findings indicated that, overall, the adolescents showed significantly more internalizing than externalizing behaviors. Using cutoff points provided by Achenbach and Rescorla (2001), the mean internalizing score fell within the clinical range and the mean externalizing score within the normal range. There was also a significant positive relationship between these two behaviors both in the natal females and the natal males. The natal males presented with significantly more internalizing behaviors than the natal females; however, no significant difference was observed between the genders in terms of the number of externalizing behaviors and total problems. We discuss the implications of these findings with regard to clinical work.

Author/-s:       Elin Skagerberg; Sarah Davidson; Polly Carmichael

Publication:     International Journal of Transgenderism, 2013

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

Background: Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results.

Aims: To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder.

Method: Data were collected within the European Network for the Investigation of Gender Incongruence using the Mini International Neuropsychiatric Interview – Plus and the Structured Clinical Interview for DSM-IV Axis II Disorders (n = 305).

Results: In 38 % of the individuals with gender identity disorder a current DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and anxiety disorders. Furthermore, almost 70 % had a current and lifetime diagnosis. All four countries showed a similar prevalence, except for affective and anxiety disorders, and no difference was found between individuals with early-onset and late-onset disorder. An Axis II diagnosis was found in 15 % of all individuals with gender identity disorder, which is comparable to the general population.

Conclusions: People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.

Author/-s:       Gunter Heylens;  Els Elaut; Baudewijntje P. C. Kreukels; Muirne C. S. Paap; Susanne Cerwenka; Hertha Richter-Appelt; Peggy T. Cohen-Kettenis; Ira R. Haraldsen; Griet de Cuypere

Publication:     The British Journal of Psychiatry, 2013

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Erlebte Genderdysphorie und psychisches Wohlbefinden bei transsexuellen Personen

The study at hand aimed to examine the construct of gender dysphoria both theoretically and empirically. Since gender dysphoria will become the new diagnosis for gender identity disorder (GID) in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), accompanied by a paradigm shift, perceiving “Transsexuality” no longer as psychiatric condition but natural variation of gender expression, obliging definitions and valid measurements become more important in the future. Within the “European Initiative for the Investigation of Gender Incongruence” (ENIGI) it is measured as part of the diagnostic process via different instruments. Two measures, the “Utrecht Gender Dysphoria Scale” (UGDS) and the “Gender Identity/ Gender Dysphoria Questionnaire for Adolescents and Adults” (GII) were explicitly examined for their definitions of gender dysphoria and evaluated for their congruence in seizing it. Furthermore, the connections between gender dysphoria and gender identity as well as psychological wellbeing were observed. Gender dysphoria was found to be differently defined in the two instruments which lead to slightly different findings in the subgroups of gender and age of onset. While the UGDS defines Gender dysphoria as the rejection of one´s body and cross-gender identification the GII conceptualizes it as the pathological counterpart of a (healthy) gender identity. The relation between gender dysphoria and gender identity revealed differences in subgroups as well. Finally only a very low level of self-reported psychopathology was found. Depression and anxiety related problems could be detected within this sample although still relatively low. Ultimately both measures of gender dysphoria seem to be useful instruments for future practice, but they also are in need of refinement with regard to contents and adaption to the new concept of gender dysphoria as used in DSM-5.

Author/-s:       Catharina Schneider

Publication:     Master Thesis, Faculty for Psychology, Universität Wien, 2012

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

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals.

Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety.

Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F=4.362, p=0.038; F=14.589, p=0.001; F=9.523, p=0.002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively).

Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Author/-s:       Esther Gómez-Gil; Leire Zubiaurre-Elorza; Isabel Esteva; Antonio Guillamon; Teresa Godás; M. Cruz Almaraz; Irene Halperin; Manel Salamero

Publication:     Psychoneuroendocrinology, 2012

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

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

Author/-s:       J. Drescher; Peggy T. Cohen-Kettenis; S. Winter

Publication:     International review of psychiatry, 2012

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P-1340 – Presence of psychiatric symptoms and personality profiles among transexuals: is gender identity disorder a true clinical entity?

Introduction: Gender identity disorder (GID) is defined as a strong and persisting cross-gender identification, associated to the discomfort with the biological sex with which subjects were born. Over the last years, the question whether GID really represents a true psychiatric disorder and if it should be included within the upcoming editions of the major diagnostic psychiatric systems or not is generating growing controversies.

Objectives: Although GID represents a major challenge for the whole medical community, involves different specialists and posits relevant treatment issues, the scientific literature concerning the psychological and clinical characteristics of GID is still limited and further studies are needed in the field.

Aims: The present research is aimed to explore the psychological, personality and clinical profile of subjects with DIG.

Methods: To this aim, 100 consecutive adult patients with a standardized DSM-IV-TR diagnosis of GID, were recruited from those attending the dedicated day-care facilities of the Department of Psychiatry of the University of Bari. All included subjects underwent a psychopathological evaluation including general psychopathology (SCL-90), personality traits (MMPI-2), anxiety and depression (Zung scales for anxiety and depression, respectively) self-rated assessment.

Results: Preliminary analyses confirmed that GID subjects did not show pathological personality traits and did not reach standardized cut-off scores for anxiety, depression, or any other general psychopathological item.

Conclusions: These results are in line with recent findings on the topic and support the notion that transexualism, although possibly causing negative feelings and psychological distress, might be not considered a psychiatric disorder.

Author/-s:       C. Palumbo; M. Tyropani; V. Pace; O. Todarello

Publication:     European Psychiatry, 2012

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

Background: Research into the association between Gender Identity Disorder (GID) and psychological disturbances as well as on its relation with parenting experiences yielded mixed results, with different patterns for Male-to-Female (MF) and Female-to-Male (FM) transsexual subjects. We investigated vulnerability markers of maladjustment and their possible origins in MF and FM transsexuals by examining maladaptive core beliefs and parenting behaviors thought to be specifically related to them.

Methods: Dysfunctional core beliefs, parenting experiences and psychiatric symptoms were assessed by the Young Schema Questionnaire indexing 19 Early Maladaptive Schemas (EMS), the Young Parenting Inventory and the Symptom Checklist-90-R, respectively, in 30 MF, 17 FM transsexual and 114 control subjects (43 males, 114 females).

Results: Subjects with GID demonstrated a level of psychiatric distress comparable to that of controls. They did display elevated scores, however, on multiple EMSs compared to nontranssexual subjects, indicating feelings of isolation, emotional deprivation and an urge to meet others’ needs, with MF transsexuals conceptualizing themselves also as more vulnerable and deficient than controls. Parenting experiences of transsexual subjects were characterised by increased maternal dominance, emotional abuse and neglect compared to controls, with males being exposed to a disengaged maternal style and more paternal emotional neglect and criticism. Both MF and FM transsexuals were made felt that in areas of achievement they will inevitably fail.

Conclusions: There is no evidence of elevated levels of psychiatric symptoms in GID, but potential predisposing factors, particularly in MF transsexuals, are present; these may originate from the more intense rejection they experience.

Author/-s:       Lajos Simon; Unoka Zsolt; Dora Fogd; Pál Czobor

Publication:     Journal of Behavior Therapy and Experimental Psychiatry, 2011

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Psychiatric comorbidity in gender dysphoric adolescents

Background: This study examined psychiatric comorbidity in adolescents with a gender identity disorder (GID). We focused on its relation to gender, type of GID diagnosis and eligibility for medical interventions (puberty suppression and cross-sex hormones).

Methods: To ascertain DSM-IV diagnoses, the Diagnostic Interview Schedule for Children (DISC) was administered to parents of 105 gender dysphoric adolescents.

Results: 67.6% had no concurrent psychiatric disorder. Anxiety disorders occurred in 21%, mood disorders in 12.4% and disruptive disorders in 11.4% of the adolescents. Compared with natal females (n = 52), natal males (n = 53) suffered more often from two or more comorbid diagnoses (22.6% vs. 7.7%, p = .03), mood disorders (20.8% vs. 3.8%, p = .008) and social anxiety disorder (15.1% vs. 3.8%, p = .049). Adolescents with GID considered to be ‘delayed eligible’ for medical treatment were older [15.6 years (SD = 1.6) vs. 14.1 years (SD = 2.2), p = .001], their intelligence was lower [91.6 (SD = 12.4) vs. 99.1 (SD = 12.8), p = .011] and a lower percentage was living with both parents (23% vs. 64%, p < .001). Although the two groups did not differ in the prevalence of psychiatric comorbidity, the respective odds ratios (‘delayed eligible’ adolescents vs. ‘immediately eligible’ adolescents) were >1.0 for all psychiatric diagnoses except specific phobia.

Conclusions: Despite the suffering resulting from the incongruence between experienced and assigned gender at the start of puberty, the majority of gender dysphoric adolescents do not have co-occurring psychiatric problems. Delayed eligibility for medical interventions is associated with psychiatric comorbidity although other factors are of importance as well.

Author/-s:       Annelou L. C. de Vries; Theo A. H. Doreleijers; Thomas Dirk Steensma; Peggy T. Cohen-Kettenis

Publication:     Journal of Child Psychology and Psychiatry, 2011

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Quality of life and sexual health after sex reassignment surgery in transsexual men

Introduction: Although sexual health after genital surgery is an important outcome factor for many transsexual persons, little attention has been attributed to this subject.

Aims: To provide data on quality of life and sexual health after sex reassignment surgery (SRS) in transsexual men.

Methods: A single-center, cross-sectional study in 49 transsexual men (mean age 37 years) after long-term testosterone therapy and on average 8 years after SRS. Ninety-four percent of the participants had phalloplasty.

Main outcome measures: Self-reported physical and mental health using the Dutch version of the Short Form-36 Health Survey; sexual functioning before and after SRS using a newly constructed specific questionnaire.

Results: Compared with a Dutch reference population of community-dwelling men, transsexual men scored well on self-perceived physical and mental health. The majority reported having been sexually active before hormone treatment, with more than a quarter having been vaginally penetrated frequently before starting hormone therapy. There was a tendency toward less vaginal involvement during hormone therapy and before SRS. Most participants reported an increase in frequency of masturbation, sexual arousal, and ability to achieve orgasm after testosterone treatment and SRS. Almost all participants were able to achieve orgasm during masturbation and sexual intercourse, and the majority reported a change in orgasmic feelings toward a more powerful and shorter orgasm. Surgical satisfaction was high, despite a relatively high complication rate.

Conclusion: Results of the current study indicate transsexual men generally have a good quality of life and experience satisfactory sexual function after SRS.

Author/-s:       Katrien Wierckx; Eva van Caenegem; Els Elaut; David Dedecker; Fleur van de Peer; Kaatje Toye; Steven Weyers; Piet Hoebeke; Stan Monstrey; Griet de Cuypere; Guy T’Sjoen

Publication:     The journal of sexual medicine, 2011

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Gender Dysphoria in Adolescents – Mental Health and Treatment Evaluation

Summary: There is increasing evidence that biological, psychological and social factors all play a role in typical gender identity development. In contrast, our understanding of gender variant development and GID remains limited.

In chapter two, we present a review of studies on the psychosexual outcome in individuals with disorders of sex development (DSD) which provides some insight into the complex relationship between biological and psychosocial factors. A high percentage of affected individuals in these studies did suffer from gender dysphoria. However, these percentages varied substantially among the different DSD groups, ranging from 0 to 67%, indicating that many individuals with DSD exhibit no gender identity problems. Clearly, a distinction should be made between gender role behavior and gender identity. Whereas there are empirical findings suggesting that biological factors, especially prenatal sex hormones, influence the development of gender role behavior, there is less evidence that biological factors affect gender identity development. Hence, the findings suggest that both biological and psychosocial factors play a role in gender variant develop ment similar to the role they play in typical gender identity develop ment. In addition, the studies on individuals with DSD indicate that patients who chose to make a gender change often did so in adolescence or young adulthood.

In chapter three psychological (dys-)functioning of adolescents with GID was compared to that of adults with GID. Age adapted versions of the same instrument, the Minnesota Multiphasic Personality Inventory (MMPI-2 or MMPI-A, respectively) were administered to adults and adolescents eligible for medical intervention (cross-sex hormones and puberty suppression, respectively). Most notable, psychological functioning of adolescents was more favorable compared to adults. Whereas 73% of the adults showed problem behavior in the clinical range on two or more clinical scales, in the adolescents this was only 32%. Further findings were that, contrary to what is found in some studies (for a review, see Lawrence, Murad) no differences in psychological functioning were found in the adult transsexuals with regard to sexual orientation (sexually attracted to natal or non-natal gender). All adolescents were sexually attracted to their natal gender. Gender differences emerged as well: adult female-to-males (FtMs) functioned significantly better than adult male-to-females (MtFs) on three clinical scales. However, adolescent FtMs functioned significantly better than adolescent MtFs on only one clinical scale and the reverse was true on two clinical scales.
The salient finding in this study was the poorer psychological functioning of adult applicants for sex reassignment compared to adolescent applicants. This may reflect a better psychological functioning of early-onset GID as opposed to late-onset (after puberty) GID. However, it also suggests that it is easier to make a gender role change around the start of puberty than in adulthood.

In chapter four the co-occurrence of autism spectrum disorders (ASD) and GID was examined in children and adolescents (115 boys and 89 girls, mean age 10.8) referred to a gender identity clinic. During the standardized assessment, a GID diagnosis was made and suspected ASD cases were identified. The Dutch version of the Diagnostic Interview for Social and Communication Disorders (10th rev., DISCO-10) was administered to ascertain ASD classifications. The incidence of ASD in the combined sample of children and adolescents was 7.8% (n=16), in the 108 assessed children 6.4% (n=7) and in the 96 assessed adolescents 9.4% (n=9). The incidence of ASD was higher in in children and adolescents with a GID-NOS (gender identity disorder not otherwise specified) diagnosis than in youth fulfilling the complete GID criteria (in children 6.5% (n=5) versus 1.9% (n=1) and in adolescents 37.5% (n=3) versus 13% (n=6) respectively). The mean IQ of the children with ASD (M=82.0) was significantly lower compared to the mean IQ of the children without ASD (M=103.9). Adolescents with ASD (M=15.4 years) were significantly older than adolescents without ASD (M=13.8 years).

The observed incidence of 7.8% ASD in the combined sample of 204 children and adolescents referred to a gender identity clinic is approximately ten times higher than the prevalence of 0.6 %–1 % of ASD in the general population. This confirms the clinical impression that ASD occurs more frequently in gender dysphoric individuals than expected by chance. The cases described in the current study illustrate the clinical management issues that arise in youth with co-occurring GID and ASD. In all, the diagnostic procedure was extended to disentangle whether the gender dysphoria evolved from a general feeling of being ‘different’ or a ‘core’ cross-gender identity. Concerning gender reassignment, ASD does not have to be a strict exclusion criterion. However, to provide individuals with co-occurring gender dysphoria and ASD with proper care remains a challenge.

In chapter five, a study on psychiatric comorbidity in adolescents with GID was presented. To ascertain DSM-IV diagnoses, the Diagnostic Interview Schedule for Children (DISC) was administered to parents of 105 gender dysphoric adolescents (mean age at assessment 14.6 years, 53 natal males and 52 natal females). Of the 105 adolescents, 32.4% had at least one concurrent psychiatric disorder, and 15.2% had two or more comorbid diagnoses. Anxiety disorders occurred in 21%, mood disorders in 12.4% and disruptive disorders in 11.4% of the adolescents. Compared with natal females, natal males suffered more often from mood disorders (20.8% versus 3.8%) and social anxiety disorder (15.1% versus 3.8%). Adolescents were divided into an immediately eligible group, when the diagnostic procedure took less than 1.5 years and a delayed eligible group, when their diagnostic procedure took 1.5 years or more. The rate for oppositional defiant disorder and the rate for three or more comorbid diagnoses was higher in delayed eligible adolescents with GID (15.4% versus 3.2% and 7.4% versus 0%, respectively) compared with immediately eligible adolescents, their age was older (15.6 years versus 14.1 years) and their intelligence was lower (TIQ=91.6 versus 99.2).
We concluded that the majority of gender dysphoric adolescents do not have co-occurring psychiatric problems, despite their increased suffering from the incongruence between experienced and assigned gender after puberty had started. However, subgroups of adolescents do show comorbid psychiatric problems. Natal males seem to need more clinical attention than natal females. Contrary to our expectation, psychiatric comorbidity by itself was only minimally associated with eligibility for medical inter-ventions. Other factors, like age, intelligence and family circumstances, seem to be of importance too.

In chapter six, the effects of puberty suppression on psychological functioning and gender dysphoria were evaluated, shortly before cross-sex hormone treatment was initiated, in adolescents with GID who had received GnRHa to suppress puberty. The first 70 eligible candidates who received puberty suppression between 2000 and 2008 were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment. Behavioral and emotional problems, depressive symptoms, anxiety and anger, general functioning, gender dysphoria and body satisfaction were assessed. Behavioral and emotional problems and depressive symptoms decreased whereas general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both genders, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1.

By relieving the acute distress accompanying the gender dysphoria, puberty suppression seemed to have offered these youths the possibility of healthy psychological development.

Long term outcome of young adults after their gender reassignment surgery who had been treated with puberty suppression during adolescence was assessed in chapter seven. For this study, we investigated gender dysphoria, treatment satisfaction, current life situation and school or employment career, sexual functioning and quality of life. Twenty-seven young adults (11 FtMs and 16 MtFs) were assessed twice: first, shortly after their attendance at the gender identity clinic (pre-treatment, mean age 13.5 (SD 1.8)) and second, at least one year after their GRS (post-treatment, mean age 20.9 (SD 1.0)). Gender dysphoria resolved and participants were predominantly satisfied with their bodies and treatment. Concerning relationships with family and peers, and professional and educational careers, they had made important age appropriate developmental transitions. Although, compared to their peers in the general Dutch population, participants showed less experience with various sexual behaviors, the number of experiences had increased after gender reassignment surgery. Many young adults (78 %) had been involved in romantic relationships. Quality of life appeared to be better compared with scores from 21–30 year old participants from a survey on the psychometric properties of the WHOQOL-Bref. Pre-treatment intelligence and poor peer relations correlated negatively with post-treatment quality of life. These findings suggest that clinical management including puberty suppression, enabled these formerly gender dysphoric adolescents to make important age appropriate developmental transitions, contributing to a satisfactory qualify of life. A subgroup of adolescents, however, showing a poorer quality of life post-treatment, deserves special clinical attention.

Author/-s:       Annelou L. C. de Vries

Publication:     Dissertation, Vrije Universiteit Amsterdam, 2010

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Psychiatric comorbidity among patients with gender identity disorder

Aims: Psychiatric comorbidity and mental instability seem to be important unfavorable prognostic factors for long-term psychosocial adjustment in gender identity disorder (GID). However, psychiatric comorbidity in patients with GID has rarely been assessed. In this study, we investigated the psychiatric comorbidity and life events of patients with GID in Japan.

Methods: A total of 603 consecutive patients were evaluated independently by at least two senior psychiatrists at the GID clinic using clinical information and results of examinations.

Results: Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7 %, 38/579) and anxiety disorder (3.6 %, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4 %, 8/579).

Conclusions: Comparison with previous reports on the psychiatric comorbidity among GID patients revealed that the majority of GID patients had no psychiatric comorbidity. GID is a diagnostic entity in its own right, not necessarily associated with severe comorbid psychological findings.

Author/-s:       Masahiko Hoshiai; Yosuke Matsumoto; Toshiki Sato; Masaru Ohnishi; Nobuyuki Okabe; Yuki Kishimoto; Seishi Terada; Shigetoshi Kuroda

Publication:     Psychiatry and clinical neurosciences, 2010

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Borderline personality disorder and transsexualism

Objective: The study addresses the question whether, as often assumed, the symptoms of borderline personality disorders occur more frequently in transsexuals or not.

Methods: We examined 164 transsexuals. The subjects completed the following questionnaires: The Borderline-Personality Inventory (BPI), the Freiburg Personality Inventory (FPI) and the Questionnaire for Assessment of One's Own Body (FbeK).

Results: In 80 % of all the examined transsexuals, there was evidence of symptoms of neither a borderline personality disorder nor of other personality disorders. If borderline symptoms occurred, they were predictable from the variables depressivity, low composure, low sociability and lack of confidence in relation to the external appearance.

Conclusions: The data obtained refute the often-assumed increased relationship between borderline personality disorders and transsexuality. It should be assumed that a borderline personality disorder is primarily a psychiatric illness, while transsexuality is a disorder of gender identity in which secondary borderline symptoms may arise in some cases.

Author/-s:       Kurt Seikowski; Sabine Gollek; Wolfgang Harth; Michaela Reinhardt

Publication:     Psychiatrische Praxis, 2008

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Gender dysphoric children – Causes, Social Functioning and Consequences

The studies described in this thesis cover four main themes. First, we addressed the assessment of gender identity disorder (GID)/gender dysphoria. Second, we examined three potential determinants of GID in childhood. Third, we investigated the (social) consequences of having a GID in childhood. Fourth, we studied the long-term psychosexual outcome of gender-referred children.

Psychometric research: In chapter 2 we reported on a cross-national, cross-clinic comparative analysis of an instrument, called the Gender Identity Interview for Children (GIIC). The GIIC was administered to 376 gender-referred children from a gender identity clinic in Toronto, Canada, 228 gender-referred children from our own clinic, and 180 control children from Toronto (M age: 7.65 yrs). Factor analysis identified a strong one-factor solution that contained all 12 items on the GIIC, accounting for 32.4% of the total variance. Probands from both clinics had a significantly higher deviant score than the controls, with effect sizes of d = 1.72 for the Canadian probands and d =2.98 for the Dutch probands. The Dutch probands had significantly higher deviant scores than the Canadian gender probands. As expected, probands in both clinics who met complete DSM criteria for GID had a significantly higher deviant score than probands sub-threshold for the diagnosis. Using cutoff scores of 3+ or 4+ deviant responses yielded specificity rates of 86.1% and 92.8%, respectively, for the controls. Sensitivity rates were higher for the Dutch probands than for the Toronto probands. This study was the first to report on the discriminant validity of the GIIC in a sample of children outside of North America.

Chapter 3 reported on results of a cross-national, cross-clinic comparative analysis of a quantitative and standardized parent-report measure of gender identity and gender role behavior named the Gender Identity Questionnaire for Children (GIQC). Data of 338 gender-referred children from Toronto were compared with data of 156 gender-referred children from Utrecht/Amsterdam (the Utrecht clinic was transferred to Amsterdam in 2002). First of all, the probands from both clinics had higher cross-gender scores than the controls, providing evidence for the validity of the instrument. The percentages of children in the two clinics who met complete DSM criteria of GID were comparable. There were also differences between the clinics. The gender-referred boys from Utrecht/Amsterdam had a significantly lower total score (indicating more cross-gender behavior) than the gender-referred boys from Toronto, but there was no significant difference for girls. In the Toronto sample, the gender-referred girls had a significantly higher total score than the gender-referred boys, but there was no significant sex difference in the Utrecht/Amsterdam sample. Across both clinics, the GIQC total score was significantly lower for the gender-referred children who met the complete DSM criteria for GID, than the gender-referred children who were sub-threshold for GID (Cohen's d = 1.08). This result provides evidence for the validity of the GID diagnosis and is the first to demonstrate this in a cross-national, cross-clinic comparative context. The results also provide some support for cross-clinic consistency in clinician-based diagnosis of GID.

Potential determinants of GID: In chapter 4 we reported on a study assessing anxiety and stress in 25 children with GID and 25 control children by measuring their cortisol, heart rate (HR) and skin conductance levels (SCL), and asking them to report their moods and experience of control. By using an established psychological challenge involving provocation and frustration, we investigated whether children with GID as compared to controls without GID reacted in a more anxious way. The gender dysphoric children reported more negative emotions than the controls and had a tonically elevated SCL. There were no differences between the groups in cortisol and HR. This study lends some support to the idea that children with GID have a more anxious nature as compared to controls.

Chapter 5 concerns the prevalence and type of co-morbidity in gender dysphoric children, examined with the Diagnostic Interview Schedule for Children-Parent version (DISC-P). We assessed psychopathology according to the DSM in two groups of children. The first group consisted of 120 Dutch children (age range: 4–11) who were referred to our Gender Identity Clinic (GID group), and the second group consisted of 47 Dutch children who were referred to an ADHD clinic (ADHD group). We found that 52% of the children diagnosed with GID had one or more diagnoses other than GID. As expected, more internalizing (37%) than externalizing (23%) psychopathology was present in both boys and girls. Furthermore, the odds of having internalizing or externalizing co-morbidity were higher in the clinical comparison group (ADHD group) than in the GID group (odds ratios were 1.28 and 1.39, respectively). Finally, 31% of the children with GID suffered from an anxiety disorder. From the results of this categorical diagnostic study we concluded that children with GID are at risk for developing co-occurring problems, that internalizing disorders were not indicative for children with GID, and that, as 69% of the children did not suffer from an anxiety disorder, a full-blown anxiety disorder does not seem to be a necessary condition for the development of GID.

Chapter 6 addressed parental characteristics to test Zucker and Bradley’s hypotheses about the role of parents in the development of GID. We examined psychological problems in parents of gender dysphoric boys and girls, and compared these results with results from two control groups in order to examine parental psychopathology as a potentially contributing factor in GID.

Furthermore, we examined parent-child interaction style of these parents to test Zucker and Bradley’s hypothesis that parents of gender dysphoric children lack the ability to set limits on their children’s behavior, cross-gender behavior included. In this study, three groups of parents were compared with respect to psychological functioning and parent-child interaction style. The first group (GID group) consisted of parents of 120 children (85 boys and 35 girls) who were referred to our Gender Identity Clinic, the second group was a clinical control group (CC group) consisting of parents of 25 children (18 boys and 7 girls) who were referred to two child psychiatric outpatient clinics, and the third group was a non-referred control group (NC group) consisting of parents of 35 non-referred boys and 27 non-referred girls (total n = 62). Parental functioning was measured with the Symptom Checklist 90-R, the Beck Depression Inventory and with a Dutch questionnaire that assesses personality disorders (‘Vragenlijst Kenmerken Persoonlijkheid’ or VKP). Parent-child interaction was measured with a Dutch questionnaire (the ‘Ouder-Kind Interactie Vragenlijst-Revised’ or OKIV-R). Except for some anxiety symptoms in a subgroup of mothers of boys with GID, parents of children with GID generally did not report more psychological problems than parents of non-referred children. Also, parents of children with GID had a constructive parent-child interaction style. We concluded that parental psychological functioning as such is not a major risk factor for GID development.

In Chapter 7 we reported on a study testing the most prominently assumed biological determinant of GID: prenatal brain exposure to testosterone. We used an indirect method for investigating the effects of prenatal exposure to testosterone: the 2D:4D finger ratio – the relative lengths of the 2nd (“index”) finger and the 4th (“ring”) finger. This marker is assumed to reflect prenatal brain exposure to testosterone and has been intensively studied in relation to postnatal behaviour and sexual orientation (for a meta-analytic study, see Hönnekopp, Bartholdt, Beier, Liebert, 2007). In our study finger ratios of 85 children with GID were compared to finger ratios of 137 control children. Furthermore, we compared the 2D:4D ratios of 96 male and 51 female adult individuals with GID to that of heterosexual male and female adult controls. In the sample of adults with GID, we classified their sexual orientation as either homosexual or non-homosexual (in relation to their birth sex) in order to examine whether or not there were any within-group differences as a function of sexual orientation. We found, as expected, for both hands a normative sex difference in the finger ratio: boys and men had significantly lower finger ratios than girls and females. However, there were no significant differences between the children with GID and their controls and we also found no evidence for an altered 2D:4D ratio in adult males with GID (in both homosexual and non-homosexual patients). We did, however, find a significantly masculinized 2D:4D ratio in adult females with GID (with a co-occurring homosexual orientation). Our own study, together with two other studies, found some support for a different finger ratio pattern in adults with GID.

Social consequences: In chapter 8 we reported on a study examining the social position of children referred to our clinic because of gender dysphoria and investigated whether they are victimized at school. Using a peer nomination technique, we examined whether classmates perceive the gender dysphoric child as a victim of bullying and/or as their friend. Twenty-eight gender dysphoric children (14 boys and 14 girls) and their classmates (n = 495) were included (mean age: 10.5 years). We found that gender-referred children did have friends at school, but hardly any same-sex friends. With regard to social acceptance, we found a sex difference: male classmates rejected gender dysphoric boys, whereas female classmates did not reject gender dysphoric girls. However, neither gender dysphoric boys nor girls were bullied at school. From our study it seems that homophobic bullying is not very prevalent at Dutch schools, and that gender dysphoric children are socially quite well accepted.

Psychosexual outcome: Chapter 9 reports on the psychosexual outcomes of gender-referred children who were assessed in childhood. At the time of the study, they were 16 years of age or older. This was also the first study that prospectively examined whether childhood characteristics were related to psychosexual outcome. We assessed gender dysphoria, sexual orientation and psychological functioning in 54 children (mean age: 18.9; age range at the time of the study: 16–28 years) who had been referred to the Gender Identity Clinic in childhood (mean age: 8.4; age range at first assessment 5–12). Twenty-three other children (Non-responders group), who had been referred in the same period, were not traceable. We found that 27% (n = 21) of the total group of 77 children were still gender dysphoric (Persistence group) and 43% percent of the children (n = 33; Desistence group) were no longer gender dysphoric in adolescence or young adulthood. Children in the Persistence group had more severe GID symptoms in childhood than the children in the other two groups. At followup, nearly all participants in the Persistence group reported having a homosexual or bisexual preference, whereas in the Desistence group only half had a homosexual or bisexual preference. Our study indicated that, despite the fairly high percentage of GID persistence, the majority will desist. Furthermore, the children with more extreme forms of gender dysphoria in childhood were more likely to persist than children with less extreme forms. With regard to sexual orientation, the most likely outcome was homosexuality or bisexuality.

Author/-s:       Madeleine Sophie Christine Wallien

Publication:     Dissertation, Vrije Universiteit Amsterdam, 2008

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MMPI–2 Characteristics of Transsexuals Requesting Sex Reassignment: Comparison of Patients in Pre-hormonal and Presurgical Phases

To assess psychopathology in transsexuals at different phases of sex reassignment, we administered the Spanish adaptation of the MMPI–2 (Ávila-Espada & Jiménez-Gómez, 1999) to 107 male-to-female and 56 female-to-male transsexuals. Except for the Mf scale, mean T scores from the Clinical scales were within the normal range and did not differ between sexes. Male-to-female transsexuals seeking sex reassignment hormonal therapy, but not female-to-male patients, scored significantly higher on the Depression, Hysteria, Psychopathic Deviate, Schizophrenia, and Social Introversion scales than patients seeking sex-reassignment surgery. The results show that the majority of patients were free of psychopathology. Transsexuals in the initial phases of sex reassignment may experience more distress than in later phases; however, these results are unlikely to reflect clinically relevant differences.

Author/-s:       Esther Gómez-Gil; Angela Vidal-Hagemeijer; Manel Salamero-Baró

Publication:     Journal of Personality Assessment, 2008

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T04-P-03 Gender identity disorder and psychiatric comorbidity: a descriptive study

Objectives: The presence of psychiatric comorbidity in patients with Gender Identity Disorder (GID) is still a matter of debate. In particular the relationship between Gender Identity Disorder and severe psychopathology is a vexed (non conosco questo termine) question.

The aim of this study is to investigate the presence of psychiatric comorbidity in a G.I.D. sample.

Materials and Method: Our sample was composed of 95 patients attending to CIDIGeM, a Public Health Service for GID people, to enter the program for Sex Reassignment Surgery.

According to international standard of care, all the patients underwent an accurate diagnosis about their gender disorder for 6 months, in order to investigate the co-morbid psychiatric condition and to ascertain eligibility and readiness for hormone and surgical therapy.

We assessed all the patients with psychological and psychiatric interviews and particularly with Semi-Structured Clinical Interview (SCID I-II) to investigate Axis I-II disorders.

Results: Preliminary data don’t show high rate of psychiatric comorbidity that is about 30 % (especially for mild mood and anxiety disorder).

Conclusion: According to our results GID is an independent clinical condition, not necessary related to severe psychopathology. The psychiatric comorbidity is often a psychological reaction to GID condition and it is not a contraindication to the gender reassignment.

Author/-s:       A. Gualerzi; C. Crespi; G. Angelini; M. Molo; Luigi Rolle; C. Manieri; V. Villari; F. Bogetto; D. Fontana

Publication:     Sexologies, 2008

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Psychiatric comorbidity among children with gender identity disorder

Objective: To investigate the prevalence and type of comorbidity in children with gender identity disorder (GID).

Methods: The Diagnostic Interview Schedule for Children-Parent version was used to assess psychopathology according to the DSM in two groups of children. The first group consisted of 120 Dutch children (age range 4–11 years) who were referred to a gender identity clinic between 1998 and 2004 (GID group) and the second group consisted of 47 Dutch children who were referred to an attention-deficit/hyperactivity disorder (ADHD) clinic between 1998 and 2004 (ADHD group; 100 % response rate for both groups).

Results: Fifty-two percent of the children diagnosed with GID had one or more diagnoses other than GID. As expected, more internalizing (37 %) than externalizing (23 %) psychopathology was present in both boys and girls. Furthermore, the odds ratios of having internalizing or externalizing comorbidity were 1.28 and 1.39 times higher, respectively, in the clinical comparison group (ADHD group) than in the GID group. Finally, 31 % of the children with GID suffered from an anxiety disorder.

Conclusions: The results of this categorical diagnostic study show that children with GID are at risk for developing co-occurring problems. Because 69% of the children do not have an anxiety disorder, a full-blown anxiety disorder does not seem to be a necessary condition for the development of GID. Clinicians working with children with GID should be aware of the risk for co-occurring psychiatric problems and must realize that externalizing comorbidity, if present, can make a child with GID more vulnerable to social ostracism.

Author/-s:       M. S. Wallien; H. Swaab; Peggy T. Cohen-Kettenis

Publication:     Journal of the American Academy of Child and Adolescent Psychiatry, 2007

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

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed.

Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure.

Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment.

Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors.

Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Author/-s:       Griet de Cuypere; Els Elaut; Gunter Heylens; G. Van Maele; G. Selvaggi; G. T’Sjoen; R. Rubens P. Hoebeke; S. Monstrey

Publication:     Sexologies, 2006

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Adolescents who are Eligible for Sex Reassignment Surgery: Parental Reports of Emotional and Behavioural Problems

One important reason why clinicians abstain from medical intervention in transsexual adolescents is that they assume that transsexualism and psychopathology are necessarily associated. However, several studies among transsexual adolescents considered eligible for sex reassignment, employing self-report questionnaires and the Rorschach according to Exner’s Comprehensive System, did not find the high levels of psychopathology encountered in psychiatric populations. Thus far, no data have been gathered from sources other than the patients themselves. It has been argued that the method used may create a bias, as the sources of information were persons who have a stake in the outcome. In this study we therefore assessed the number and type of psychological problems among transsexual adolescents using Child Behavior Checklist and DISC data gathered from parents or other caretakers, at the time of application. In about one quarter of the patients DSM criteria were fulfilled (one specific phobia, one tic disorder, one oppositional disorder and one anxiety disorder), and in about one third of the patients, parents reported high levels of behavioural or emotional problems on the Child Behavior Checklist (CBCL). A post hoc qualitative inspection of the clinical CBCL group’s situation revealed that in all patients important unfavourable family circumstances could be observed, such as having major conflicts with parents. This might have led to an over-reporting of problems by parents or may be indicative of a real elevation of emotional or behavioural disturbance, perhaps as a reaction of family problems that already existed or were a consequence of the child’s gender dysphoria. However, in line with previous data, transsexual adolescents as a group did not score in the clinical range at the time of application.

Author/-s:       Peggy T. Cohen-Kettenis; Stephanie H. M. van Goozen

Publication:     Clinical Child Psychology and Psychiatry, 2002

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Treatment follow-up of transsexual patients. A catamnestic study

In a retrospective study, 33 transsexual patients, 22 male-to-female transsexual (MF-TS), and 11 female-to-male transsexuals (FM-TS), were interviewed 53-121 months after their first referral to the psychiatric department of a university hospital. Social integration proved to be satisfactory and relatively stable. Twenty-five patients had gone through surgical sex reassignment, while 29 were currently undergoing hormonal treatment. Regarding the course of treatment, the FM-TS were a more homogeneous group than the MF-TS group. Overall, physical and psychosocial well-being was satisfactory. Psychometric measures yielded remarkably normal values, with some pathological findings regarding personality traits. In the majority of patients, self- and observer-rating appraisals of gender-specific physical appearance were equally positive. The results suggest a three-step procedure for the treatment of transsexual patients, as is practiced in other centers within German speaking continental Europe.

Author/-s:       Urs Hepp; R. Klaghofer; R. Burkhard-Kübler; C. Buddeberg

Publication:     Der Nervenarzt, 2002

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Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorders and healthy adults

Objective: Gender dysphoric patients of transsexual type (TS) have been considered to have severe psychopathology. However, these notions have a weak empirical documentation.

Method: 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.

Results: 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.

Conclusion: 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.

Author/-s:       Ira R. Haraldsen; A. A. Dahl

Publication:     Acta Psychiatrica Scandinavia, 2000

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Utility of the MMPI-2 in assessing gender dysphoric patients

We compared MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles of 2 groups of adult biological men requesting sex reassignment surgery; 1 group was diagnosed with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) transsexualism and the other with gender identity disorder of adolescence and adulthood, nontranssexual type (GIDAANT). Although the mean profiles for the transsexual group did not demonstrate any psychopathology, the GIDAANT group showed moderate psychopathology. A cluster analysis indicated that 85% of the transsexual group showed low psychopathology and 47% of the GIDAANT group showed severe psychopathology. Neither the MMPI-2 results nor the DSM-III-R clinical evaluation support the conclusion of many authors that transsexualism is associated with severe personality disorder; rather, the data indicate that transsexualism and other gender identity disorders without persistent wish for sex reassignment differ significantly in degree of psychopathology.

Author/-s:       Patricia P. Miach; Ellen F. Berah; James N. Butcher; Steve Rouse

Publication:     Journal of Personality Assessment, 2000

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Comorbidity of gender dysphoria and other major psychiatric diagnoses

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.

Author/-s:       Collier M. Cole; Michael O’Boyle; Lee E. Emory; Walter. J. Meyer III

Publication:     Archives of Sexual Behavior, 1997

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Psychological Functioning of Adolescent Transsexuals: Personality and Psychopathology

Adolescent transsexuals were compared with adolescent psychiatric outpatients and first-year university students to determine the extent to which other psychopathology is a necessary condition for the development of transsexualism. Three areas of psychological functioning associated with fundamental psychological disturbances—perceptual inaccuracy, disorders of thought and negative self-image—were assessed by means of the Rorschach Comprehensive System. The group of adolescent transsexuals was found to be intermediate between adolescent psychiatric patients and nonpatients for extent of perceptual inaccuracy. They did not differ significantly from nonpatients with regard to thinking disturbances and negative self-image. The psychiatric patients included significantly more individuals characterized by negative self-image than the other groups. The results support the idea that major psychopathology is not required for the development of transsexualism.

Author/-s:       Leo Cohen; Corine de Ruiter; Heleen Ringelberg; Peggy T. Cohen–Kettenis

Publication:     Journal of Clinical Psychology, 1997

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Sex reassignment of adolescent transsexuals: a follow-up study

Objective: To investigate postoperative functioning of the first 22 consecutive adolescent transsexual patients of our gender clinic who underwent sex reassignment surgery.

Method: The subjects were interviewed by an independent psychologist and filled out a test battery containing questionnaires on their psychological, social, and sexual functioning. All subjects had undergone surgery no less than 1 year before the study took place. Twelve subjects had started hormone treatment between 16 and 18 years of age. The posttreatment data of each patient were compared with his or her own pretreatment data.

Results: Postoperatively the group was no longer gender-dysphoric; they scored in the normal range with respect to a number of different psychological measures and they were socially functioning quite well. Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.

Conclusions: Starting the sex reassignment procedure before adulthood results in favorable postoperative functioning, provided that careful diagnosis takes place in a specialized gender team and that the criteria for starting the procedure early are stringent.

Author/-s:       Peggy T. Cohen-Kettenis; Stephanie H. M. van Goozen

Publication:     Journal of the American Academy of Child and Adolescent Psychiatry, 1997

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MMPI results of male candidates for transsexual surgery

The MMPI was administered to a group of 27 male transsexual candidates for sex change surgery, and their test results were compared with those of 24 male kidney transplant surgical candidates and 26 males suspected of having a psychophysiological disorder. The data revealed a notable absence of psychopathology among the transsexuals as well as the kidney patients, while the psychophysiological patients showed the expected elevations in the Hypochondriasis, Depression, and Hysteria scales. The results were in keeping with previous research of male-to-female sex change candidates that reject the notion that transsexuals invariably suffer major emotional disturbance.

Author/-s:       W. T. Tsushima; D. Wedding

Publication:     Journal of personality assessment, 1979

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