International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20

Mental health and gender dysphoria: A review of

the literature

Cecilia Dhejne, Roy Van Vlerken, Gunter Heylens & Jon Arcelus

To cite this article: Cecilia Dhejne, Roy Van Vlerken, Gunter Heylens & Jon Arcelus (2016)
Mental health and gender dysphoria: A review of the literature, International Review of
Psychiatry, 28:1, 44-57, DOI: 10.3109/09540261.2015.1115753

To link to this article: http://dx.doi.org/10.3109/09540261.2015.1115753

Published online: 02 Feb 2016.

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 INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
VOL. 28, NO. 1, 44–57
http://dx.doi.org/10.3109/09540261.2015.1115753

REVIEW ARTICLE

Mental health and gender dysphoria: A review of the literature

Cecilia Dhejnea, Roy Van Vlerkenb, Gunter Heylensc and Jon Arcelusd,e
a
Gender Team, Centre for Andrology and Sexual Medicine and Centre for Psychiatry Research, Department of Clinical Neuroscience,
Karolinska Institute and University Hospital, Stockholm, Sweden; bCentre of Expertise on Gender Dysphoria, VU University Medical Centre,
Amsterdam, Netherlands; cCentre for Sexology and Gender, University Hospital, Ghent, Belgium; dNottingham Centre for Gender
Dysphoria, Nottingham, UK; eDivision of Psychiatry and Applied Psychology, Faculty of Medicine & Health Sciences, University of
Nottingham, Nottingham, UK

ABSTRACT ARTICLE HISTORY

Studies investigating the prevalence of psychiatric disorders among trans individuals have Received 2 July 2015
Downloaded by [Ghent University], [gunter heylens] at 08:19 04 February 2016

identified elevated rates of psychopathology. Research has also provided conflicting psychiatric Revised 30 October 2015
outcomes following gender-confirming medical interventions. This review identifies 38 cross- Accepted 30 October 2015
sectional and longitudinal studies describing prevalence rates of psychiatric disorders and Published online 28 January
psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with 2016
gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric KEYWORDS
disorders in trans people attending services at the time of assessment are higher than in the cis Gender dysphoria; trans-
population, they do improve following gender-confirming medical intervention, in many cases sexualism; mental health;
reaching normative values. The main Axis I psychiatric disorders were found to be depression and psychiatric disorders;
anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, depression; anxiety
were rare and were no more prevalent than in the general population. There was conflicting
evidence regarding gender differences: some studies found higher psychopathology in trans
women, while others found no differences between gender groups. Although many studies were
methodologically weak, and included people at different stages of transition within the same
cohort of patients, overall this review indicates that trans people attending transgender health-care
services appear to have a higher risk of psychiatric morbidity (that improves following treatment),
and thus confirms the vulnerability of this population.

Introduction 2. To assess for psychiatric co-morbidity

The Standards of Care for the Health of Transsexual, 3. To explore the readiness for gender-confirming
Transgender, and Gender Nonconforming People, ver- medical intervention (Coleman et al., 2012).
sion 7 (SOC-7) by the World Professional Association 4. To support the trans person through the health
for Transgender Health (WPATH), provides clinical pathway (Lev, 2009).
guidance in ‘how to assist transsexual, transgender, and Although some professionals in the field have
gender nonconforming people with safe and effective described the involvement of a mental health profes-
pathways to achieving lasting personal comfort with sional in the care of trans people as a responsible form of
their gendered selves, in order to maximize their overall care (Selvaggi & Giordano, 2014), it could be argued that
health, psychological well-being, and self-fulfilment. This this is the direct result of transsexualism or gender
assistance may include primary care, gynaecological and dysphoria being considered a psychiatric diagnosis. The
urological care, reproductive options, voice and com- placement of the diagnoses (either gender dysphoria or
munication therapy, mental health services (e.g. assess- transsexualism) within the Diagnostic and Statistical
ment, counselling, psychotherapy), and hormonal and Manual of Mental Disorders (DSM) (American
surgical treatments’ (Coleman et al., 2012). SOC-7 argues Psychiatric Association, 2013), and within the Mental
that the mental health professional should work within a and Behavioural Disorders chapter of the International
multi-disciplinary team or in close contact with other Classification of Diseases and Health Related Problems
gender specialists. The main roles of mental health (World Health Organization, 1992), has been subject to
professionals within gender care have been described as: continuing debate. The first appearance of these diag-
1. To facilitate the diagnosis of gender dysphoria noses in the aforementioned publications (using different

CONTACT Cecilia Dhejne, MD [email protected] Gender Team, Centre for Andrology and Sexual Medicine and Centre for Psychiatry Research,
Department of Clinical Neuroscience, Karolinska Institute and University Hospital, Stockholm, Sweden
ß 2016 Taylor & Francis
 INTERNATIONAL REVIEW OF PSYCHIATRY 45

terms) may be related to the social and medical attitudes suicidality, autism, eating disorders or individuals
at the time when Harry Benjamin started to describe and under 18 years old were not included, as they are part
treat trans people (Drescher et al., 2012). Whether of other reviews within this special edition. Only studies
incongruence with one’s gender is a natural variation or in English and with more than 10 participants were
a pathology, and how this view may influence discrim- selected.
ination, stigma and access to medical treatment, is well
discussed in a paper by Meyer-Bahlburg (2010).
Information sources and search
The WHO’s proposal for the next edition of the ICD
(ICD-11) is to replace the current diagnostic term An electronic literature search was conducted between
‘transsexualism’ with ‘gender incongruence’, and to January 2000 and April 2015 using PubMed. Articles in
move this diagnosis from chapter 5 to a new chapter the International Journal of Transgenderism (not in
entitled ‘Conditions related to sexual health’ (Drescher PubMed) were also included, in order to identify more
et al., 2012). This will support the view of many that a studies. Additionally, reference sections of identified
diagnosis describing trans people should not be part of a articles were also examined for further relevant publica-
psychiatric category (Richards et al., 2015). This could tions. The search used the following words in the title
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help to remove some of the stigma which trans people and/or abstract.
currently encounter. However, by doing so, it also raises 1. For terms referring to trans people: transsexualism,
questions concerning the future role, if any, of mental transsexual, transgender, gender dysphoria, gender
health professionals in transgender care. identity disorder, trans*
One of the roles may be connected to the high 2. For psychiatric disorders and psychopathology:
prevalence of psychiatric morbidity among trans people mental health, psychopathology, psychiatric, depres-
described in the literature (Gomez-Gil et al., 2009; Hepp sion, anxiety
et al., 2005; Heylens et al., 2014a; Mazaheri Meybodi
et al., 2014a), which may require assessment and Every term used for trans people was combined using
management by a mental health professional. The the ‘or’ and the ‘and’ operator with every term used for
literature in this area is confusing, as different prevalence psychiatric disorders and psychopathology.
rates of psychiatric co-morbidity have been described.
With this in mind, this paper has two aims: Study selection
1. To review the available literature that looks at the A total of 647 studies were identified. By the screening of
prevalence of psychiatric disorders and psychopath- titles and abstracts, 47 studies fulfilled the eligibility
ology among trans people criteria and were selected for more in-depth analysis.
2. To review the available literature describing the Out of these 47 studies, nine were excluded because they
psychiatric outcome following gender-confirming did not provide data regarding psychiatric disorders or
medical interventions (GCMI), either cross-sex psychopathology, but focused primarily on quality of life
hormone treatment (CHT) and/or gender-confirm- or sexual health, thus a total of 38 studies were selected
ing genital surgery (GCGS) for this review. Data extraction was performed using a
standardized table with the following categories: title,
As the terminology in this field has changed over the
authors, date of publication, participants, age at assess-
years, the term ‘trans people’ will be used in this review
ment, study design, diagnostic criteria used, control
to refer to individuals with gender dysphoria attending
group, measurements related to psychiatric disorder and/
transgender health-care services and, in most cases,
or psychopathology, prevalence rates of psychiatric
seeking gender-confirming medical interventions.
disorders, and conclusions of the study. For those
papers investigating outcome, information regarding
Methodology follow-up was also included, as well as the outcome
on psychopathology and/or psychiatric disorders. The
Eligibility criteria
data is summarized in two tables: Table 1 shows
Studies were selected only if participants were diagnosed cross-sectional studies describing prevalence rates of
by health professionals, and/or had been accepted for psychiatric disorders and/or psychopathology in trans
gender-confirming interventions, and had empirical data people (27 studies). This table includes trans people
relating to the prevalence of psychiatric morbidity or at different stages of treatment. Table 2 shows longitu-
psychopathology pre- or post-treatment. Articles dealing dinal studies describing psychiatric outcome of post
exclusively with self-harm (non-suicidal self-injury), gender-confirming medical interventions (11 studies).
 Downloaded by [Ghent University], [gunter heylens] at 08:19 04 February 2016

46

Table 1. Cross-sectional studies investigating psychiatric disorders and psychopathology in trans people.
Number of
trans participants/
diagnosis/ Treatment status:
Authors (year) mean age at (on CHT or Comparative Outcome
Country assessment post-GCGS) Study design groups measure Prevalence in trans Conclusion
C. DHEJNE ET AL.

Haraldsen & Dahl 35 FtM CHT NR Single centre CC 1068 SCID-I Axis 1 disorders (mostly depression and Groups: Trans lower scores in SCL-90R
(2000) 51 MtF GCGS Mixed pre- (Gender clinic) Personality SCID-II anxiety) 32.5% than PD
Norway DSM-III-R and Cross-sectional disorder GAF Axis 2 disorders 19.8% Gender:
DSM-IV post-surgery (PD) 101 SCL-90R SCL-90R as per CC MtF lower SCL-90R compared to FtM
34.0 years FtM
33.3 years MtF
Miach et al. (2000) 82 MtF: CHT NR Single centre GID vs GIDAANT MMPI-2 Psycho-pathology: GID differs significantly in degree of
Australia 48 GID GCGS 0% (Gender clinic) Low in 85% of GID psycho-pathology from GIDAANT
34 GIDAANT Cross-sectional High in 47% of GIDAANT
DSM-III-R
33.5 years
Kersting et al. 12 FtM CHT NR Single centre Psychiatric DES Dissociative symptoms: DES and SCID-D limited validity in trans
(2003) 29 MtF GCGS 17% (Gender clinic) inpatients 115 SCID-D Trans similar to psychiatric inpatients people
Germany DSM-IV Cross-sectional Normative data
34.7 years
Hepp et al. (2005) 11 FtM CHT 32% Single centre No SCID-I, -II Axis I disorder current Gender, age, treatment status: No
Switzerland 20 MtF GCGS 23% (Gender clinic) HADS (mostly anxiety) 38.7% differences
DSM-IV Cross-sectional Axis I disorder, lifetime (mostly mood
33.2 years disorder and substance abuse) 71%
Axis II disorder 41.9%
Kim et al. (2006) 43 MtF CHT 88% Single centre Cis men 47 BDI BDI (mean) 21.4 Trans significantly higher scores on
Korea DSM-IV GCGS 26% (Identified as Matched for age SADS SADS (mean) 13.6 depression and social anxiety, and
20.4 years part of the and SES SES (mean) 16.5 lower scores on self-esteem than
military service education controls
examination
with gender dys-
phoria)
Cross-sectional
Gomez-Gil et al. 56 FtM CHT NR Single centre Normative data MMPI-2 MMPI: Within normal range Gender:
(2008)a 107 MtF GCGS 0% (Gender clinic) MtF not on CHT scored higher
Spain DSM-IV Cross-sectional than on CHT
27.3 years FtM FtM no difference regarding CHT status
29.9 years MtF Limitation: Pre-/post groups not the same
Gomez-Gil et al. 159 MtF CHT 49% Single centre No MINI Psychiatric disorders Adjustment disorders and substance
(2009)a 71 FtM GCGS 0% (Gender clinic) Life time: Mood and adjustment disorders abuse more frequent in MtF vs FtM
Spain DSM-IV-TR Cross-sectional 56% (MtF) and 70.4% (FtM)
ICD-10 Non-alcohol substance abuse/
27.3 years FtM dependence 30.2% (MtF)
29.7 years MtF Generalized anxiety disorder 8.8% (MtF)
and 5.6% (FtM)
Current: Social phobia 8.2% (MtF) and
11.3% (FtM)
(continued)
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Table 1. Continued

Number of
trans participants/
diagnosis/ Treatment status:
Authors (year) mean age at (on CHT or Comparative Outcome
Country assessment post-GCGS) Study design groups measure Prevalence in trans Conclusion
Madeddu et al. 34 MtF CHT 36% Single centre No SCID-II Axis II disorders 52% No Axis II differences between genders
(2009) 16 FtM GCGS 0% (Gender clinic) Most frequent PD Narcissistic
Italy DSM-IV-TR Cross-sectional
31.7 years
Weyers et al. 50 MtF CHT 100% Single centre Normative data SF-36 Mental health problems: Less Psychopathology if in a relationship
(2009) ICD-10 GCGS 100% (Gender clinic) No difference to normative data
Belgium 43.06 years Cross-sectional
Hoshiai et al. 349 FtM CHT 32% Single centre No Clinical interview Axis I disorder 13.6% Adjustment MtF more Axis I disorders
(2010) 230 MtF GCGS 12% (Gender clinic) and clinical records disorder 6.7% compared to FtM
Japan DSM-IV Cross-sectional Anxiety disorder 3.6%
26.5 years FtM Mood disorder 1.4%
32.0 years MtF
Bandini et al. 109 MtF CHT 70.6% GCGS Single centre Trans with and Psychiatric Psychiatric disorder (life time): CM group higher body dissatisfaction and
(2011)b DSM-IV-TR 25.7% (Gender clinics) without childhood interview 66.7% (CM) worse life time mental health
Italy 36.0 years Cross-sectional maltreatment (CM) SCL-90R 37.2% (non-CM)
SCL-90R: no difference between groups
Dhejne et al. 191 MtF CHT NR Multi centre CC 3240 matched Death (including When compared to 1973-2003 controls: Gender: no difference, natal or
(2011) 133 FtM GCGS 100% (National register) for age, natal and suicide) Mortality 2.8 HRadj assigned gender
Sweden ICD-8,-9,-10 Cross-sectional new assigned Psychiatric morbid- Any psychiatry diagnoses: 2.8 HRadj Female or male control group:
33.3 years FtM gender ity and abuse Suicide attempts: No difference
36.3 years MtF 4.9 HRadj
When compared 1989-2003 to controls:
Mortality the same.
Any psychiatry diagnoses: 2.8 HRadj
Suicide attempts: the same
Simon et al. (2011) 30 MtF CHT NR Single centre CC¼ 157 SCL-90R Psychopathology: MtF elevated levels of
Hungary 17 FtM GCGS 0% (Gender clinic) SCL-90R: No differences compared interpersonal sensitivity
DSM-IV Cross-sectional to controls
28.0 years FtM
26.0 years MtF
Gomez-Gil et al. 74 FtM CHT 35.8% Single centre Trans with and SADS Social anxiety, depression and anxiety: Gender: No difference
(2012)a 113 MtF GCGS 42.2% (Gender clinic) without treatment HAD-A SADS, HADS scores normal range except CHT: CHT group better when
Spain ICD-10 Cross-sectional Normative data HAD-D for HAD-A compared to not treated
DSM-IV-TR Differences CHT or not: CHT group Limitation: Pre-/post groups
29.7 years lower scores were not the same
Gorin-Lazard et al. 30 FtM CHT 72.1% Multi centre No BDI Depression: Gender: no difference
(2012)c 31 MtF GCGS NR (Gender clinic) 25% significant scores in the BDI
France DSM-IV-TR Cross-sectional
29.9 years FtM
39.4 years MtF
Auer et al. (2013) 32 FtM CHT 100% Single centre CC 336 age and SCL-90R Psychopathology: Gender:
Germany 57 MtF GCGS 65% (Endocrinology sex (natal and SCL-90R worse scores on all scales Depressive symptoms higher in MtF
ICD-10 clinic) phenotype) compared controls FtM have profile as cis men
INTERNATIONAL REVIEW OF PSYCHIATRY

Cross-sectional matched MtF more similar to cis women

(continued)
47
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48

Table 1. Continued

Number of
trans participants/
diagnosis/ Treatment status:
Authors (year) mean age at (on CHT or Comparative Outcome
Country assessment post-GCGS) Study design groups measure Prevalence in trans Conclusion
32.3 years FtM
47.9 years MtF
C. DHEJNE ET AL.

b
Fisher et al. (2013) 92 MtF CHT 69.8% GCGS Single centre No SCID-I-II Axis I disorders 18.7% Gender: no difference
Italy 48 FtM 22.1% (Gender clinic) SCL-90R Mood and adjustment disorder 10.8%
DSM-IV-TR Cross-sectional Anxiety disorder 5%
32.6 years Axis II disorders 4.3%
Gorin-Lazard et al. 31FtM CHT 73.1% Multi-centre Trans with and BDI Depression and self-esteem: NA
(2013)c 36 MtF GCGS NR (Gender clinics) without CHT SSEI Trans on CHT less depressive symptoms, Limitation:
France DSM-IV-TR Cross-sectional better self esteem Pre-/post groups were not the same
35.1 years
Davey et al. (2014) 63 MtF CHT 78.6% Single centre CC 103 SCL-90R Psychopathology: Social support did not significantly predict
UK 40 FtM GCGS 16.5% (Gender clinic) Controlled by age SCL-90R scores higher in trans psychopathology
ICD-10 Cross-sectional
45.7 years
Duisin et al. (2014) 21 MtF CHT NR Single centre CC 30 SCID-II Axis-II diagnosis 66.6% (most Difference: GID group more Axis-II
Serbia 9 FtM GCGS 0% (Gender clinic) frequent paranoid and avoidant) disorders compared to CC group
DSM-IV-TR Cross-sectional Gender: MtF more psychopathology
30.4 years compared to FtM
Fisher et al. (2014)b 59 FtM CHT 0% Multi-centre Trans with SCL-90R Psychopathology: Body uneasiness effectively diminished
Italy 66 MtF GCGS NR (Gender clinics) and without CHT BUT GSI No difference between both on SCL-90R with CHT
DSM-IV-TR Cross-sectional BUT GSI: MtF with CHT group had less Limitation: Pre-/post groups were
28.7 years FtM body uneasiness than not treated group not the same
33.1 years MtF
Judge et al. (2014) 159 MtF CHT 20.2% Single centre No Psychiatric assess- Depression (lifetime) 34.4% High prevalence of psychiatric conditions
Ireland 59 FtM GCGS 1.6% (Gender clinic) ment by mental Schizophrenia 3.67% Limitation: No controls
DSM-IV-TR Cross-sectional health professional Bipolar disorder 2.29%
32.6 years
Heylens et al. 182 MtF CHT 0% Multicentre No MINI Axis I diagnosis (current) 38% Affective Gender, age of onset: No differences
(2014a) 123 FtM GCGS 0% 4 countries Cross- SCID-II problems 27%
Belgium DSM-IV-TR sectional Anxiety problems 17%
Germany 22.8-31.2 years Axis I (current and lifetime) 70%
Netherlands FtM Affective problems 60%
Norway 21.6-36.5 years Anxiety problems 28%
MtF Axis II diagnosis 15%
(Depends on
country)
Mazaheri Meybodi 47 MtF CHT 92.9% Single centre No SCID-I Axis-I diagnosis 62.7% High prevalence of Axis I diagnosis
et al. (2014a) 36 FtM GCGS 0% (Gender clinic) Major depressive disorder (33.7%) Limitation:
Iran DSM-IV-TR Cross-sectional Specific phobia (20.5%) No controls
Age: NR Adjustment disorder (15.7%)
Mazaheri Meybodi 39 MtF CHT 92.9% Single centre No MCMI-II Axis II diagnosis 81.4% (57.1% narcissistic) High prevalence of Axis II diagnosis
et al. (2014b) 31 FtM GCGS 0% (Gender clinic) Limitation:
Iran DSM-IV-TR Cross-sectional No controls
Age: NR
Claes et al. (2015) 103 MtF CHT 0% No SCL-90R Psychopathology:
UK 52 FtM GCGS 0% RSE MtF reported significantly higher scores
(continued)
 INTERNATIONAL REVIEW OF PSYCHIATRY 49

Inventory, second version; MtF, male to female subjects, trans women; NR, not reported; RSE, Rosenberg Self-Esteem scale; SADS, Social Avoidance and Distress Scale; SCID-I and II, Structured Clinical Interview for DSM-IV,
MtF significantly lower level of self-esteem

BDI, Beck depression inventory; BUT-GSI, Body Uneasiness Test Global Severity Index (the total score of BUT); CC, Cis controls; CHT, ¼ cross-sex hormonal treatment; DES, Dissociative Experience Scale; DDIS, Dissociative
Disorders Interview Schedule; FtM, female-to-male subjects, trans men; GAF, Global Assessment of Functioning Scale; GCGS, gender confirmation genital surgery; GD, Gender dysphoria; GID, gender identity disorder;
GIDAANT, gender identity disorder of adolescence and adulthood, non-transsexual type; GSI, Global Severity Index; HADS, Hospital Anxiety and Depression Scale; HAD-A, HAD-Anxiety subscale to HADS; HAD-D, HAD-

Axis I and II disorders; SCID-D, Structured Clinical Interview for DSM-IV-Dissociative Disorders; SCL-90R, Symptom Checklist-90 (revised); SES, Self-Esteem Scale; SF-36, Short Form 36-item Questionnaire; SSEI, Social Self
Depression sub scale to HADS; HRadj, adjusted hazard ratio; MINI, Mini International Neuropsychiatric Interview; MMPI-2, Minnesota Multiphasic Personality Inventory, second version; MCMI-II, Millon Clinical Multiaxial
Description of studies
Cross-sectional studies
The 27 studies were all conducted in different
transgender health-care services or gender identity
clinic services, using data collected as part of the

compared to FtM
assessment (whether prospectively or retrospectively).

No differences
The diagnosis was made according to DSM criteria
Conclusion

(ranging from DSM-III-R to DSM-5) (American

Gender:
Gender:

Psychiatric Association, 1987, 1994, 2000, 2013) and,

in six studies, according to the ICD-10 (World Health
compulsive complaints compared with
trust, anxiety, depression and obsessive-
on paranoid ideation, interpersonal dis-

Organization, 1992). Only three studies described

psychiatric co-morbidity and/or psychopathology in
patients exclusively without any form of treatment
Dissociative disorders 29.6%

for gender dysphoria (Claes et al., 2015; Colizzi et al.,

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2015; Heylens et al., 2014a). The remainder of the

studies included people at different stages of treat-
Prevalence in trans

ment, or the treatment status was unknown or not

reported. Only five studies were multi-centred and,
with the exception of one (Kim et al., 2006),
FtM

participants were all recruited through transgender

health-care services.
The studies concluded that the prevalence of
psychiatric co-morbidity and psychopathology was
Outcome
measure

high. However, only seven studies used a control

DDIS

group, and only four of them matched the cis controls

DES

with the trans population studied for factors known to

affect psychopathology (such as age). Most studies
used normative data to reach a conclusion as to
Comparative

whether the prevalence found was high or not. The

groups

most commonly used measurement to assess for

No

psychiatric disorders was the Structured Clinical

Interview for DSM (SCID) (First et al., 2002), and
for psychopathology, the Symptom Checklist -90 (SCL-
Cross-sectional

Cross-sectional
(Gender clinic)

(Gender clinic)
Single centre

Single centre
Study design

90) (Derogatis et al., 2010). For more details, please

see Table 1.

Longitudinal studies
Treatment status:

The 11 longitudinal studies evaluate changes in psychi-

post-GCGS)
(on CHT or

GCGS 0%

atric disorders and/or psychopathology following

CHT 0%

gender-confirming medical interventions. Three studies

assess the patients following cross-sex hormones, six
trans participants/

following gender-confirming genital surgery, and two

studies following both treatments. Six of the studies also
mean age at
assessment
Number of

DSM-IV-TR

Studies using the same data.

34.5 years

30.2 years
diagnosis/

provide cross-sectional data pretreatment compared with

85 MtF
33 FtM
ICD-10

normative values. The information regarding follow-up

time was recorded in all of the studies and ranged from
-Esteem Inventory.
Table 1. Continued

Colizzi et al. (2015)

six months (Udeze et al., 2008) to 13.3 years (Ruppin &

Pfäfflin, 2015). Lost to follow-up ranged from 0%
Authors (year)

(Colizzi et al., 2013, 2014) to 49.3% (Ruppin & Pfäfflin,

Country

2015). For more information about these studies, see

Italy

a,b,c

Table 2.
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50

Table 2. Follow up studies investigating outcome of psychiatric disorders and psychopathology post gender treatment in trans people.
Number of trans Treatment
participants/ status:
Authors (year) diagnosis/ mean (on CHT or Comparative Length of follow- Lost to Outcome
Country age at assessment post GCGS) Study design groups up post-treatment follow-up measure Results
Slabbekoorn et al. 47 FtM CHT 100% Single centre Pre- vs post-CHT 14 weeks post-CHT 0 AIM Differences pre-/post-treatment:
(2001) 54 MtF GCGS 0% (Gender Clinic) SAQ MtF: positive emotions increased
C. DHEJNE ET AL.

Netherlands DSM-III-R Prospective after CHT

25.7 years FtM FtM less intensity for both nega-
32.9 years MtF tive and positive emotions after
CHT
Smith et al. (2001) 13 FtM CHT 100% Single centre Pre- vs post-GCGS 1–4 years post- 17% Dutch Short MMPI Differences pre-/post-treatment:
Netherlands 7 MtF GCGS 100% (Gender clinic) Control: 21 GCGS SCL-90 Treated group no longer gender
DSM-III-R Prospective patients who 1–7 years dysphoric, psychologically and
16.6 years have been controls socially functioning well.
denied/ declined Neither group showed significant
GCGS differences between pre- and
post-GCGS on SCL-90
Smith et al. (2005) 71 FtM CHT 100% Single centre Pre- vs post-GCGS 1–4 years post- 16% UGDS Cross-sectional pretreatment: As
Netherlands 117MtF GCGS 100% (Gender clinic) Normative GCGS Dutch Short MMPI normative data
DSM-IV Prospective SCL-90 Differences pre-/post-treatment:
29.6y FtM Fewer psychological problems
38.6y MtF post-treatment.
Gender dysphoria absence post-
treatment
Predictors:
FtM psychological better outcome
than MtF
Heterosexual as per natal sex
worse outcome
De Cuypere et al. 27 FtM CHT 100% Single centre Pre- vs post-GCGS 4.1 years MtF 42% UGDS Cross-sectional pretreatment: SCL-
(2006) 35 MtF GCGS 100% (Gender clinic) Normative 7.6 years FtM SCL-90 90 as normative data
Belgium Diagnosis: NR Retrospective Differences pre-/post-treatment:
26.9 years FtM Fewer psychological problems
37.8 years MtF post-treatment.
(pre-GCGS) Gender dysphoria absence post-
treatment.
Suicide attempt drop from 29.3%
to 5.1%
Predictors:
Younger when applying for GCGS
and attractive better outcome.
Udeze et al. (2008) 40 MtF CHT NR Single centre Pre- vs post-GCGS 0.5 years NR SCL-90R Cross-sectional pre-treatment: no
UK DSM-IV GCGS 100% (Gender clinic) post-GCGS Psychiatric clinical psychiatric diagnosis
47.3 years Prospective interview for Differences pre-/post-treatment:
ICD-10 No differences in SCL-90R scores
Limitation: scores of SCL-90 low
already at pretreatment
14 FtM CHT 88% Multicentre Pre- vs post-GCGS 9 years 30% Psychiatric Cross-sectional pretreatment: 30–
18 MtF GCGS 100% (2 gender clinics) post-GCGS symptoms 50% insomnia, depression or
(continued)
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Table 2. Continued

Number of trans Treatment

participants/ status:
Authors (year) diagnosis/ mean (on CHT or Comparative Length of follow- Lost to Outcome
Country age at assessment post GCGS) Study design groups up post-treatment follow-up measure Results
Johansson et al. ICD-10 Prospective Global outcome anxiety. 7.1% received ongoing
(2010) 27.8 years FtM patient and psychiatric treatment.
Sweden 37.3 years MtF clinician Differences pre-/post-treatment:
Global clinician outcome:
Improved 62%
Unchanged 24%.
Global patient outcome:
Improved 95%
Worse 5%.
Gender: no differences
Age of onset: no differences
Pimenoff & Pfäfflin 17 FtM CHT 100% Single centre Pre- vs post-GCGS 5 years 16.2% University of Differences pre-/post-treatment:
(2011) 15 MtF GCGS 100% (Gender clinic) post-GCGS Minnesota Psychological and social function-
Finland Diagnosis NR Retrospective Questionnaire ing improved significantly
37.5 years FtM Gender: No differences except for
44.4 years MtF vocational functioning which
was better for FtM
Colizzi et al. 25 FtM CHT 100% Single centre Pre- vs post-CHT 1 year post-CHT 0 PSS Differences pre-/post-treatment:
(2013)* 45 MtF GCGS 0% (Gender clinic) Perceived stress lower post-treat-
Italy DSM-IV-TR Prospective ment and as per normative data
26.7 years FtM
29.2 years MtF
Colizzi et al. 29 FtM CHT 100% Single centre Pre- vs post-CHT 1 year post-CHT 0 SCID-1 Cross-sectional pre-treatment: SAS
(2014)* 78 MtF GCGS NR (Gender clinic) Normative SAS above normal range
Italy DSM-IV-TR Prospective SDS SDS and SCL-90R in normal range
26.7 years FtM SCL-90R except anxiety subscale
29.2 years MtF Differences pre-post treatment:
SAS, SDS, SCL-90R scores lower
post CHT
Heylens et al. 11FtM CHT 100% Single centre Pre- vs post-CHT 3–6 months post- 7.5–26.3% SCL-90 Cross-sectional pretreatment: SCL-
(2014b) 46 MtF GCGS 81% (Gender clinic) (47) vs post- CHT Psychosocial 90 worse than normative data
Belgium DSM-IV-TR Prospective GCGS (42) 1–12 months questionnaire Differences pre-/post-treatment:
NR Normative post-GCGS Post treatment SCL-90 as norma-
tive data
95% better mood 93% happier
81% less anxious
79% more self confidence
98% better body relation
Less drugs and alcohol abuse
Ruppin & Pfäfflin 36 MtF CHT 100% Single centre Pre- vs post-treat- 13.3 years 49.3% SCL-90R Differences pre-/post-treatment:
(2015) 35 MtF GCGS 97.1% (Gender clinic) ment IIP SCL-90R significantly better on all
Germany ICD-10 Retrospective FPI-R subscales post treatment par-
14.1 years FtM ticularly interpersonal sensitivity
13.7 years MtF IIP significant lower values at
follow-up
INTERNATIONAL REVIEW OF PSYCHIATRY

AIM, affect intensity measure; CHT, cross-sex hormonal treatment; FPI-R, Freiburg Personality Inventory; FtM, female to male subjects, trans men; GCGS, gender confirmation genital surgery; IIP, Inventory of Interpersonal
Problems; MMPI-2, Minnesota Multiphasic Personality Inventory, second version; MtF, male to female subjects, trans women; NA, not applicable; NR, not reported; PSS, Perceived stress scale; SCID-I, Structured Clinical
51

Interview for DSM-IV, Axis I disorders; SAS, Zung Self-Rating Anxiety Scale; SAQ, Short Anger Situation Questionnaire; SCL-90, Symptom Checklist-90; SCL-90R, Symptom Checklist-90 revised; SDS, Zung Self-Rating
Depression Scale; UGDS, Utrecht Gender Dysphoria Scale.
*Studies using the same data.
 52 C. DHEJNE ET AL.

Results Risk factors for psychopathology and psychiatric

Cross-sectional studies disorders

Psychopathology The majority of the studies comparing trans women and

trans men found no differences in psychiatric disorders
Studies investigating prevalence rates of psychopathology and psychopathology between the two groups. Four
range from rates that are comparable to the general studies did find psychiatric disorders and psychopath-
population (Colizzi et al., 2014; Simon et al., 2011; Smith ology to be more prevalent among trans women than
et al., 2005) to the trans group having worse scores than trans men (Claes et al., 2015; Duisin et al., 2014; Gomez-
the cis controls (Auer et al., 2013; Davey et al., 2014; Gil et al., 2009; Hoshiai et al., 2010). Conversely,
Heylens et al., 2014b). The prevalence and nature of Haraldsen & Dahl (2000) found that trans women
psychopathology in trans women was found to be more scored lower on the SCL-90R test than trans men.
comparable to cis women than to cis men, the former One study (Heylens et al., 2014a) found no differences
showing a two- to threefold higher occurrence of between the age of onset and psychiatric disorders.
affective problems when compared with cis men (Auer As found in the general psychiatric literature, two
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et al., 2013). studies investigating psychopathology among trans

people also found that being in a relationship was a
positive factor, associated with a reduction of psycho-
Psychiatric disorders, Axis I pathology (Gorin-Lazard et al., 2012; Weyers et al.,
The Axis I diagnoses found in all the studies reviewed 2009).
were mainly affective and anxiety disorders. The occur-
rence of severe psychiatric conditions, such as schizo- Longitudinal studies
phrenia or bipolar disorder, was rare. Only one study
looking at Axis I disorders compares a trans group with a An improvement of psychiatric morbidity and psycho-
cis control group matched for age, natal sex and new pathology following GCMI was seen in all of the studies
assigned sex (Dhejne et al., 2011). This study, which uses except one (Udeze et al., 2008). This study found no
data from the national register in Sweden, focuses on differences between pre- and post-SCL-90R scores,
trans people following gender-confirming medical inter- which is probably due to the low levels of psychopath-
ventions and found higher rates of psychiatric disorders ology as measured by the SCL-90R pretreatment. The
and suicide in this group. It found, however, that there majority of the studies found post-treatment scores on
was an improvement over time, i.e. rates of psychiatric questionnaires measuring psychopathology and gender
disorders and suicide became more similar to controls dysphoria to be similar to normative data.
over time; for the period 1989–2003, there was no
difference in the number of suicide attempts compared Predictors for positive outcome following GCMI
to controls.
Four longitudinal studies explored post-treatment out-
come predictors and found better outcomes for trans
men (Smith et al., 2005) and those who were young on
Psychiatric disorders, Axis II
assessment (De Cuypere et al., 2006). Two studies did
Only one study (Duisin et al., 2014) used a (non- not find gender or age of onset to be predictors of
matched) control group when assessing Axis II psychi- outcome following GCGS (Johansson et al., 2010;
atric disorders. This found higher rates of personality Pimenoff & Pfäfflin, 2011). Interestingly, one study
disorders in the trans group, primarily paranoid and compared patients who had been compliant with their
avoidant personality disorders. The study is limited by treatment plan with those who had not, and found no
the small number of patients studied. The rest of the differences in outcome (Pimenoff & Pfäfflin, 2011).
studies that assessed Axis II disorders did not use
control groups. The prevalence rates of Axis II
Discussion
disorders ranged from 4.3% (Fisher et al., 2013) to
81.4% (Mazaheri Meybodi et al., 2014b). The type of The aim of this review was to explore the literature in the
personality disorder varied from predominantly cluster field of mental health/psychiatry and gender dysphoria.
B (Hepp et al., 2005; Madeddu et al., 2009; Mazaheri Overall, it was found that trans people attending
Meybodi et al., 2014b) to predominantly cluster C transgender health-care services present with a high
(Heylens et al., 2014a). prevalence of psychiatric disorders and psychopathology.
 INTERNATIONAL REVIEW OF PSYCHIATRY 53

The review indicates that the level of psychopathology The majority of the psychiatric problems detailed in
appears to be higher in this population than in cis the studies relate to affective disorders such as depression
controls, although it cannot reach firm conclusions as and anxiety. Major psychiatric problems (e.g. schizo-
to whether the rate of psychiatric disorders is higher in phrenia and bipolar disorder) were not found any more
trans people than in controls, due to the lack of well- frequently in trans people than in the general population.
matched controlled studies exploring psychiatric Dissociative disorders were only evaluated in one study
disorders. (Colizzi et al., 2015).
The only study using a robust methodology concludes The results with respect to gender differences in both
that trans people present with higher levels of psychiatric pre- and post-treatment cross-sectional studies were
disorders post-GCMI than cis controls. However, this contradictory. The majority of the studies showed no
study looks at trans people who were treated in some differences between the genders, but, except for one
cases more than 20 years ago, when society and study (Haraldsen & Dahl, 2000) those studies that did
interventions may have been very different. Studies identify differences found that trans women were more
investigating the outcome of trans people who transi- prone to develop psychological/psychiatric problems
tioned a long time ago will be very different from those than trans men (Colton-Meier et al., 2013; De Cuypere
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looking at individuals who transitioned in the 21st et al., 1995; Landén et al., 1998; Lothstein, 1984). This
century, and although this study offers longer follow-up finding could indicate that trans women show a
data, these will be affected by changes in the levels of psychological and vulnerability profile for the develop-
transphobia and discrimination over time. Furthermore, ment of affective disorders that resembles that of natal
surgical results were less good at that time, which is also women (Auer et al., 2013). Biologically, this could be
known to affect transgender health negatively (Bauer explained by recent findings using neuro-imaging that
et al., 2015; Lawrence & Zucker, 2012). reveal that non-treated trans women have cerebral
The studies reviewed in this paper include trans cortical thickness similar to cis women (Zubiaurre-
people at different stages of transition within the same Elorza et al., 2012). However, the increased levels of
cohort, which is confusing, and does not allow for clear psychiatric disorders in trans women could also be
conclusions to be drawn as to the levels of psychopath- explained by the higher risk of stigma and discrimination
ology and psychiatric disorders in non-treated trans within this group; this may contribute to the interper-
people. Only one study (Heylens et al., 2014a) provides sonal problems that one study found made trans women
clear information regarding the rates of psychiatric more hypersensitive to rejection (Davey et al., 2015;
disorders pretreatment. It found that, at the time of Simon et al., 2011).
assessment and before treatment was commenced, 38% The fact that some studies that included trans
of those attending transgender health-care services people who had been treated with GCMI found
presented with an Axis I diagnosis, and 15% with an higher levels of psychopathology and psychiatric
Axis II diagnosis. disorders (Dhejne et al., 2011) than cis controls
As all of the studies use data collected at the time of cannot be used as evidence for the efficacy (or
assessment at a transgender health-care service, the otherwise) of GCMI. Studies that compared different
results regarding levels of psychopathology and psychi- cohorts of patients (pre CHT/GCGS versus post CHT/
atric disorders cannot be generalized to trans people not GCGS) are only helpful in this regard when they are
in contact with clinical services. In order to clarify well controlled for psychopathology and for known
whether there is a difference between these groups it may factors affecting psychopathology, between both
be interesting to look at studies exploring lifetime groups (Gomez-Gil et al., 2012; Gorin-Lazard et al.,
psychiatric disorders. Four studies provide this informa- 2013; Fisher et al., 2014).
tion (Bandini et al., 2011; Gomez-Gil et al., 2009; The effect that gender-confirming medical interven-
Hepp et al., 2005; Heylens et al., 2014a). Of particular tions have in improving mental health can only be
importance is the study by Heylens et al. (2014a), which concluded from longitudinal studies. This review found
showed clear differences between current (38%) and life- that longitudinal studies investigating the same cohort
time (70%) levels of psychiatric disorders. This shows of trans people pre- and post-interventions showed an
that the rate and severity of psychiatric disorders and overall improvement in psychopathology and psychi-
psychopathology may be underrepresented if data is atric disorders post-treatment. In fact, the findings from
taken only from trans people at the time they are being most studies showed that the scores of trans people
assessed at transgender health services; the rate may be following GCMI were similar to those of the general
considerably higher in those who are not on a pathway population. Although this is likely to be a response to
towards treatment. the gender-confirming treatment itself, i.e. the sense of
 54 C. DHEJNE ET AL.

the body being more aligned to the person’s experi- Implications for future research
enced gender, it cannot be ruled out that it relates
Although the studies measuring the prevalence of
instead or as well to the benefits that accrue from being
psychiatric disorders in trans people attending clinical
validated and accepted for treatment (Nuttbrock et al.,
services are robust and reach firm conclusions, future
2011). In order to help clarify this it is important to
studies could explore the rates among those trans people
look at follow-up studies that assess trans people a
not attending clinical services. Future studies could also
relatively long time after treatment. Five studies (De
benefit from more detailed and better controlled longi-
Cuypere et al., 2006; Johansson et al., 2010; Pimenoff &
tudinal studies. Due to the low prevalence of trans
Pfäfflin, 2011; Ruppin & Pfäfflin, 2015; Smith et al.,
individuals attending clinical services (Arcelus et al.,
2001) that followed trans people for more than 2 years
2015), larger cohort multicentre studies such as the
(maximum 13.3 years) post-treatment showed encoura-
European Network Initiative of Gender Incongruence
ging results that point towards the benefits of treating
(ENIGI) project (Kreukels et al., 2012) may strengthen
trans people with GCMI.
recruitment rates. Studies such as this may be limited by
Although it was not the main aim of this review, we
several factors including the variability of the interven-
also explored risk factors for psychiatric disorders among
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tions provided and the levels of discrimination and

the trans population. Victimization (social stigma, dis-
transphobia in different countries.
crimination, transphobia, sexual abuse, gender abuse), Although psychiatric morbidity should be studied as a
difficulties accessing health care and social services, secondary outcome of gender-confirming medical inter-
gender (as explained above) and interpersonal problems ventions, studies should primarily explore the role of
were all found to put trans people at risk of developing those interventions in reducing gender dysphoria. A
psychiatric disorders, particularly depression. Trans robust measure is needed to relate the primary outcome
individuals were also found to receive, or perceived for GCMI to gender dysphoria. The variability of tools to
themselves to receive, less social support from their measure gender and body dysphoria does not allow firm
family and friends than non-trans siblings and matched conclusions to be drawn, and this suggests the need for a
general population (Davey et al., 2014; Factor & stronger measurement tool.
Rothblum, 2007; Gooren et al., 2015; Kim et al., 2006; In summary, this review indicates that, although
Simon et al., 2011). Social and parental support, the levels of psychopathology and psychiatric disorders
completed medical transition, and disclosure of trans- of trans people attending transgender health-care
gender identity were all protective factors (Bandini et al., services are higher than the cis population at the
2011; Bauer et al., 2015; Bazargan & Galvan, 2012; time of assessment, they do improve following gender-
Bockting et al., 2013; Clements-Nolle et al., 2006; Davey confirming medical intervention, in many cases
et al., 2015; Gehring & Knudson, 2005; Gooren et al., reaching normative values. Information on trans
2015; Lombardi et al., 2001; Nuttbrock et al., 2011, 2014; people not in contact with services is lacking. While
Rotondi, 2011). gender-confirming medical intervention improves
mental health, trans people are still a vulnerable
group.
Quality of the studies
Almost all of the studies reviewed showed selection
Declaration of interest
bias. Since most included only individuals attending
transgender health-care services, the results are not The authors report no conflicts of interest. The
generalizable to the overall trans population. Many authors alone are responsible for the content and writing of
the paper.
studies are also limited by the inclusion of trans
people at different stages of treatment. Longitudinal
studies are also limited by lost-to-follow-up data and References
short follow-up time; only registry-based studies do American Psychiatric Association. (1987). Diagnostic and
not have lost-to-follow-up data, but their cross- Statistical Manual of Mental Disorders (3rd ed. rev.).
sectional design fails to measure improvement of Washington, DC: APA.
psychopathology within the same individual following American Psychiatric Association. (1994). Diagnostic and
GCMI. Furthermore, they are limited by the lack of Statistical Manual of Mental Disorders (4th ed.).
Washington, DC: APA.
matching according to known risk factors for psychi- American Psychiatric Association. (2000). Diagnostic and
atric disorders and psychopathology within the general Statistical Manual of Mental Disorders (4th ed., text rev.).
population (Dhejne et al., 2011). Washington, DC: APA.
 INTERNATIONAL REVIEW OF PSYCHIATRY 55

American Psychiatric Association. (2013). Diagnostic and Davey, A., Bouman, W.P., Arcelus, J., & Meyer, C. (2014).
Statistical Manual of Mental Disorders (5th ed.). Arlington, Social support and psychological well-being in gender
VA: APA. dysphoria: A comparison of patients with matched controls.
Arcelus, J., Bouman, W.P., Van De Noortgate, W., Claes, L., Journal of Sexual Medicine, 11, 2976–2985.
Witcomb, G.L., & Fernandez-Aranda, F. (2015). Systematic De Cuypere, G., Jannes, C., & Rubens, R. (1995). Psychosocial
review and meta-analysis of prevalence studies in trans- functioning of transsexuals in Belgium. Acta Psychiatrica
sexualism. European Psychiatry 30(6), 807–815. Scandinavica, 91, 180–184.
Auer, M.K., Höhne, N., Bazzara-Castro, M.A., Pfister, H., Fuss, De Cuypere, G., Elaut, E., Heylens, G., Van Maele, G., Selvaggi,
J., Stalla, G.K, . . . Ising, M. (2013). Psychopathological G., T’Sjoen, G., . . . Monstrey, S. (2006). Long-term follow
profiles in transsexuals and the challenge of their special up: Psychosocial outcome of Belgian transsexuals after sex
status among the sexes. PLoS One, 8(10), e78469. reassignment surgery. Sexologies, 15, 126–133.
Bandini, E., Fisher, AD., Ricca, J., Meriggiola, M.C., Jannini, Derogatis, L.R., & Unger, R. (2010). Symptom Checklist-
E.A., Manieri, C.,. . . Maggi, M. (2011). Childhood maltreat- 90-Revised. In Weiner, I.B. & Craighead, W.E. (Eds). Corsini
ment in subjects with male-to-female gender identity Encyclopedia of Psychology,. 4th edition. Hoboken, NJ: John
disorder. International Journal of Impotence research, 23, Wiley & Sons.
276–285. Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A.L.,
Bauer, G.R., Scheim, A.I., Pyne, J., Travers, R., & Hammond, R. Langstrom, N., & Landen, M. (2011). Long-term follow-up
Downloaded by [Ghent University], [gunter heylens] at 08:19 04 February 2016

(2015). Intervenable factors associated with suicide risk in of transsexual persons undergoing sex reassignment surgery:
transgender persons: A respondent driven sampling study in Cohort study in Sweden. PLoS One, 6, e16885.
Ontario, Canada. BMC Public Health, 15, 525. Drescher, J., Cohen-Kettenis, P., & Winter, S. (2012). Minding
Bazargan, M., & Galvan, F. (2012). Perceived discrimination the body: Situating gender identity diagnoses in the ICD-11.
and depression among low-income Latina male-to-female International Review of Psychiatry, 24(6), 568–577.
transgender women. BMC Public Health, 12, 663–671. Duisin, D., Batinic, B., Barisic, J., Djordjevic, M.L., Vujovic, S., &
Bockting, W.O., Miner, M.H., Swinburne Romine, R.E., Bizic, M. (2014). Personality disorders in persons with gender
Hamiltion, A., & Coleman E. (2013). Stigma, mental identity disorder. The Scientific World Journal, 809058.
health, and resilience in an online sample of the US Factor, R.J., & Rothblum, E.D. (2007). A study of transgender
transgender population. American Journal of Public Health, adults and their non-transgender siblings on demographic
5, 943–995. characteristics, social support, and experience of violence.
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted Journal of LGBT Health Research, 3, 11–30.
suicide among transgender persons: The influence of gender First, M.B., Spitzer, R.L., Gibbon M., and Williams, J.B.W.
–based discrimination and victimization. Journal of (2002). Structured Clinical Interview for DSM-IV-TR Axis I
Homosexuality, 3, 53–69. Disorders, Research Version, Patient Edition. (SCID-I/P),.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., New York: Biometrics Research, New York State Psychiatric
DeCuypere, G., Feldman, J., . . . Zucker, K. (2012). Standards Institute.
of care for the health of transsexual, transgender, and Fisher, A.D., Bandini, E., Casale, H., Ferrucio, N., Meriggiola,
gender-nonconforming people, version 7. International M.C., Gualerzi, A., . . . Maggi, M. (2013). Sociodemographic
Journal of Transgenderism, 13, 165–232. and clinical features of gender identity disorder: An
Colizzi, M., Costa, R., Pace, V., & Todarello, O. (2013). Italian multicentric evaluation. Journal of Sexual Medicine,
Hormonal treatment reduces psychobiological distress in 10, 408–419.
gender identity disorder, independently of the attachment Fisher, A.D., Castellini, G., Bandini, E., Casale, H., Fanni, E.,
style. Journal of Sexual Medicine, 10(12), 3049–3058. Benni, L., . . . Rellini, A.H. (2014). Cross-sex hormonal
Colizzi, M., Costa, R., & Todarello, O. (2014). Transsexual treatment and body uneasiness in individuals with gender
patients’ psychiatric comorbidity and positive effect of dysphoria. Journal of Sexual Medicine, 11, 709–719.
cross-sex hormonal treatment on mental health: Results Gehring, D., & Knudson, G. (2005). Prevalence of childhood
from a longitudinal study. Psychoneuroendocrinology, 39, trauma in a clinical population of transsexual people.
65–73. International Journal of Transgenderism, 8, 23–30.
Colizzi, M., Costa, R., & Todarello, O. (2015). Dissociative Gomez-Gil, E., Trilla, A., Salamero, M., Godas, T., &
symptoms in individuals with gender dysphoria: Is Valdes, M. (2009). Sociodemographic, clinical, and psychi-
the elevated prevalence real? Psychiatry Research, 226, atric characteristics of transsexuals from Spain. Archives of
173–180. Sexual Behavior, 38, 378–392.
Colton Meier, S., Pardo, S.T., & Labuski, C. (2013). Measures Gomez-Gil, E., Vidal-Hagemeijer, A., & Salamero, M. (2008).
of clinical health among female-to-male transgender persons MMPI-2 characteristics of transsexuals requesting sex
as a function of sexual orientation. Archives of Sexual reassignment: Comparison of patients in prehormonal and
Behavior, 42, 463–474. presurgical phases. Journal of Personality Assessment, 90,
Claes, L., Bouman, W.P., Witcomb, G., Thurston, M., & 368–374.
Arcelus, J. (2015). Non-suicidal self-injury in transsexualism: Gómez-Gil, E., Zubiaurre-Elorza, L., Esteva, I., Guillamon, A.,
Associations with psychological symptoms, victimization, Godás, T., Cruz Almaraz, M., . . . Salamero M. (2012).
interpersonal functioning and perceived social support. Hormone-treated transsexuals report less social dis-
Journal of Sexual Medicine, 12(1), 168–179. tress, anxiety and depression. Psychoneuroendocrinology,
Davey, A., Bouman, W.P., Meyer, C., & Arcelus, J. (2015). 37, 662–670.
Interpersonal functioning among individuals with gender Gooren, L.j., Sunkaew, T., Giltay, E.J., & Guadamuz, T.E.
dysphoria. Journal of Clinical Psychology, 71(12), 1173–1185. (2015). Cross-sex hormone use functional health and
 56 C. DHEJNE ET AL.

mental-being among transgender men (Toms) and Lev, A.I. (2009). The ten tasks of the mental health provider:
Transgender women (Kathoeys) in Thailand. Culture, Recommendations for revision of the world professional
Health & Sexuality, 1, 92–103. association for transgender health’s standards of care.
Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., International Journal of Transgenderism, 11, 74–99.
Gebleux, S., Penochet, J.C., . . . Bonierbale, M. (2012). Is Lothstein, L.M. (1984). Psychological testing with transsexuals:
hormonal therapy associated with better quality of life in A 30-year review. Journal Personality Assessment, 48,
transsexuals? A cross sectional study. Journal of Sexual 500–507.
Medicine, 9, 531–541. Madeddu, F., Prunas, A., & Hartmann, D. (2009). Prevalence
Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., of Axis II Disorders in a sample of clients undertaking
Penochet, J.C. Pringuey, D., . . . Auquier, P. (2013). psychiatric evaluation for sex reassignment surgery.
Hormonal therapy is associated with better self-esteem, Psychiatric Quarterly, 80, 261–267.
mood and quality of life in transsexuals. Journal of Nervous Mazaheri Meybodi, A., Hajebi, A., & Ghanbari Jolfaie, A.
and Mental Disease, 201, 996–1000. (2014a). Psychiatric Axis I Comorbidities among patients
Haraldsen, I.R., & Dahl, A.A. (2000). Symptom profiles of with gender dysphoria. Psychiatry Journal, 971814.
gender dysphoric patients of transsexual type compared to Mazaheri Meybodi, A., Hajebi, A., & Ghanbari Jolfaie, A.
patients with personality disorders and healthy adults. Acta (2014b). The frequency of personality disorders in patients
Psychiatrica Scandinavica, 102, 276–281. with gender identity disorder. Medical Journal of the Islamic
Downloaded by [Ghent University], [gunter heylens] at 08:19 04 February 2016

Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, Republic of Iran, 28, 90.
A. (2005). Psychiatric comorbidity in gender identity Meyer-Bahlburg, H.F. (2010). From mental disorder to iatro-
disorder. Journal of Psychosomatic Research, 58, 259–261. genic hypogonadism: Dilemmas in conceptualizing gender
Heylens, G., Elaut, E., Kreukels, B.P., Paap, M.C., Cerwenka, S., identity variants as psychiatric conditions. Archive of Sexual
Richter-Appelt, H., . . . De Cuypere, G. (2014a). Psychiatric Behavior, 39, 461–476.
characteristics in transsexual individuals: Multicenter study Miach, P.P., Berah, E.F., Butcher, J.N., & Rouse, S. (2000).
in four European countries. British Journal of Psychiatry, Utility of the MMPI-2 in assessing gender dysphoric
204, 151–156. patients. Journal of Personality Assessment, 75, 268–279.
Heylens G., Verroken C., De Cock S., T’sjoen G., & De Nuttbrock, L., Bockting, W., Rosenblum, A., Hwahng, S.,
Cuypere G. (2014b). Effects of different steps in gender Manson, M., Macri, M., & Becker, J. (2014). Gender abuse,
reassignment therapy on psychopathology: A prospective depressive symptoms and substance use among transgender
study of persons with a gender identity disorder. Journal of women: A 3-year prospective study. American Journal of
Sexual Medicine, 11, 119–126. Public Health, 11, 2199–2266.
Hoshiai, M., Matsumoto, Y., Sato, T., Ohnishi, M., Okabe, N., Nuttbrock, L., Bockting, W., Rosenblum, A., Manson, M.,
Kishimoto, Y., . . . Kuroda, S. (2010). Psychosomatic Macri, M., & Becker, J. (2011). Gender identity conflict/
comorbidity among patients with gender identity disorder. affirmation and major depression across the life course
Psychiatry Clinical Neurosciences, 64, 514–519. of transgender women. International Journal of
Johansson, A., Sundbom, E., Hojerback, T., & Bodlund, O. Transgenderism, 13, 91–1034.
(2010). A five-year follow-up study of Swedish adults with Pimenoff, V., & Pfäfflin, F. (2011). Transsexualism: Treatment
gender identity disorder. Archives of Sexual Behavior, 39, outcome of compliant and noncompliant patients.
1429–1437. International Journal of Transgenderism, 13, 37–44.
Judge, C., O’Donovan, C., Callaghan, G., Gaoatswe, G., Richards, C., Arcelus, J., Barrett, J., Bouman, WP., Lenihan, P,,
O’Shea, D. (2014). Gender dysphoria – prevalence and Lorimer, S., Murjan, S., & Seal, L. (2015). Trans is not a
co-morbidities in an irish adult population. Frontiers in disorder – but should still receive funding. Sexual and
Endocrinology, 5, 87. Relationship Therapy, 30, 309–313.
Kersting A., Reutemann, M., Gast, U., Ohrmann, P., Rotondi, N.K. (2011). Depression in trans people: A review of
Suslow, T., Michael, N., & Arolot, V. (2003). Dissociative the risk factors. International Journal of Transgenderism, 13,
disorders and traumatic childhood experiences in transsex- 104–116.
uals. Journal of Nervous and Mental Disease, 191, 182–189. Ruppin, U., & Pfafflin, F. (2015). Long-Term Follow-Up of
Kim, T.S., Cheon, Y.H., Pae C.U., Kim, J.J., Lee, C.U., Adults with Gender Identity Disorder. Archive of Sexual
Lee, S.J., . . . Lee, C. (2006). Psychological burdens are Behavior. 1321–1329.
associated with young male transsexuals in Korea. Psychiatry Selvaggi, G., & Giordiano, S. (2014). The role of mental health
and Clinical Neurosciences, 60, 417–421. professionals in gender reassignment surgeries: Unjust
Kreukels, B.P., Haraldsen, I.R., De Cuypere, G., Richter-Appelt, discrimination or responsible care? Aesthtetic Plastic
H., Gijs, L., & Cohen-Kettenis, P.T. (2012). A European Surgery, 38, 1177–1183.
network for the investigation of gender incongruence: The Simon, L., Zsolt, U., Fogd, D., & Czobor P. (2011).
ENIGI initiative. European Psychiatry, 27, 445–450. Dysfunctional core beliefs, perceived parenting and psycho-
Landén, M., Wålinder, J. & Lundstrom, B. (1998). Clinical pathology in gender identity disorder: A comparison of
characteristics of a total cohort of female and male male-to-female, female-to-male transsexual and nontrans-
applicants for sex reassignment: A descriptive study. Acta sexual control subject. Journal of Behavior Therapy and
Psychiatrica Scandinavica, 97, 189–194. Experimental Psychiatry, 5, 38–45.
Lawrence, A. & Zucker, K. (2012) Gender identity Slabbekoorn, D., Goozen, S.H.V., Gooren, L.J., & Cohen-
disorders. In M. Hersen & D. Beidel (Eds.), Adult Kettenis, P.T. (2001). Effects of cross-sex hormone treatment
psychopathology and diagnosis, (6th ed., pp. 601–635). on emotionality in transsexuals. International Journal of
London: Wiley. Transgenderism, 5(3), 2–18.
 INTERNATIONAL REVIEW OF PSYCHIATRY 57

Smith, Y.L., van Goosen, S.H., & Cohen-Kettenis, P.T. (2001). Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G.,
Adolescents with gender identity disorder who were Heylens, G., . . . Verstraelen, H. (2009). Long-term assess-
accepted or rejected for sex reassignment surgery: A ment of the physical, mental, and sexual health among
prospective follow-up study. Journal of the American transsexual women. Journal of Sexual Medicine, 6(3),
Academy of Child and Adolescent Psychiatry, 40, 472–481. 752–760
Smith, Y.L., van Goosen, S.H., Kuiper, A.J., & Cohen-Kettenis, World Health Organization. (1992). Manual of the
P.T. (2005). Transsexual subtypes: Clinical and theoretical International Statistical Classification of Diseases, Injuries,
significance. Psychiatry Research, 137, 151–160. and Causes of Death, Tenth Revision, Geneva: Author.
Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Zubiaurre-Elorza, L., Junque, C., Gomez-Gil, E., Segovia, S.,
Psychological functions in male-to-female transsexual Carrillo, B., Rametti, G., & Guillamon, A. (2013). Cortical
people before and after surgery. Sexual and Relationship thickness in untreated transsexuals. Cerebral Cortex, 23,
Therapy, 23, 141–145. 2855–2862.
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