Susanne Cerwenka

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.

Body Satisfaction and Physical Appearance in Gender Dysphoria

Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.

Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults

This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.

Sexual Behavior of Gender-Dysphoric Individuals Before Gender-Confirming Interventions: A European Multicenter Study

A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.

Effects of Medical Interventions on Gender Dysphoria and Body Image: A Follow-up Study

Objective The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. Methods Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). Results At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. Conclusions Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

Intimate Partnerships and Sexual Health in Gender-Dysphoric Individuals Before the Start of Medical Treatment

ABSTRACT Objectives: This study focuses on sexual health aspects in partnered gender-dysphoric individuals at the start of medical treatment by examining their partnership constellations, sexual experiences, and reports of psychological problems. Methods: As part of the cross-national European Network for the Investigation of Gender Incongruence Study, 168 adult male-to-females (MFs) and female-to-males (FMs; MF:FM sex ratio = 1:1.2) were surveyed by means of self-administered questionnaires prior to any gender-confirming hormonal and surgical interventions. Results: MFs were often found to have androphilic (female) partners (sexually oriented toward males), noncomplementary with their female gender identity. In contrast, FMs frequently had androphilic (female) partners, complementary with their male gender identity and sexual orientations toward females. Conclusions: In both genders, complementary partnership constellations were associated with more avoidance of sexual experiences and more negative sexual experiences.

Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study.

ABSTRACT We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR = 6.07). Satisfied respondents’ QoL scores were similar to reference values; dissatisfied or regretful respondents’ scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Sexuelle Orientierung und Partnerwahl transsexueller Frauen und Männer vor körpermedizinischen geschlechtsanpassenden Maßnahmen

Diverse partner relationship constellations of gender dysphoric women and men with different sexual orientations are explored in a sample of 93 persons before gender-confirming interventions in persons with female gender identity and male body characteristics (MF) and persons with male gender identity and female body characteristics (FM). While in both gender groups the majority is single, relationship patterns show differences. Apart from working life, FM already live predominantly in the new, male gender role and have partners by whom they are desired as males. In contrast, only a small proportion of MF already conduct their private lives in the new, female gender role, and they often have relationships with partners sexually attracted to males and not to their female gender identity. The findings indicate a need for differing resources for gender dysphoric women and men in the process of a transsexual course of development.Schlusselworter ● ▶ Transsexualitat ● ▶ Geschlechtsidentitats- storung ● ▶ sexuelle Orientierung ● ▶ Partnerwahl ● ▶ Partnerschaften Abstract ▼ partner relationship constellations of gender dysphoric women and men with diff e- rent sexual orientations are explored in a sample of 93 persons before gender-confi rming inter- ventions in persons with female gender identity and male body characteristics (MF) and persons with male gender identity and female body cha- racteristics (FM). While in both gender groups the majority is single, relationship patterns show diff erences. Apart from working life, FM already live predominantly in the new, male gender role and have partners by whom they are desired as males. In contrast, only a small proportion of MF already conduct their private lives in the new, female gender role, and they often have relation- ships with partners sexually attracted to males and not to their female gender identity. The fi n- dings indicate a need for diff ering resources for gender dysphoric women and men in the process of a transsexual course of development.

Recalled gender-related play behavior and peer-group preferences in childhood and adolescence among adults applying for gender-affirming treatment

ABSTRACT Norms are considered to influence expectations toward gender-related behavior. Deviations from these norms are often perceived negatively by the social environment. The objective of this study was to investigate adults diagnosed with a Gender Identity Disorder (GID), their recalled play behavior, and peer preferences in childhood and adolescence. Differences between individuals who applied for transition from female to male (FtMs) and those who applied for transition from male to female (MtFs) and between age-of-onset subgroups were explored. Data collection took place as part of the European Network for the Investigation of Gender Incongruence. The sample consisted of N = 634 participants (mean age = 30.6) diagnosed with GID according to DSM-IV-TR who were recruited between 2007 and 2012. Participants answered two questions regarding recalled play behavior and three questions on peer preferences. Nonconforming gender expression was more frequently recalled in FtMs than MtFs. Within gender groups, individuals who were categorized as early-onset recalled nonconforming gender expression more frequently than individuals who were categorized as late-onset. The results of the study are in line with previous findings indicating different phenomenological pathways in individuals applying for gender-affirming treatment that warrant attention. Factors that are considered to impact on gender-related differences in nonconforming gender expression are discussed.

EPA-1697 – Recalled gender-related play behavior and peer preferences in childhood and adolescence among adult gender-dysphoric individuals

It is frequently suggested that gender role norms influence certain expectations towards a childs gender related behavior and that deviations are perceived negatively by the social environment. Gender-dysphoric individuals experience a strong and persistent cross-gender identification and discomfort about the assigned sex and the associated gender role behaviors. The objective of this study was to investigate how adult gender dysphoric individuals recall play and peer-group preferences in childhood according to stereotypical expectations regarding the assigned sex. Differences between individuals who transition from female to male (FtMs) and those who transition from male to female (MtFs) as well as differences with regard to subgroups based on the age of onset (early onset: during childhood, EO; late onset: with begin of puberty development, LO) are tested. Data collection took place as part of the European network for the investigation of gender incongruence (ENIGI), a multicenter cooperation between European gender clinics in Amsterdam (NL), Ghent (BE), Hamburg (GER) and Oslo (NO). Play behavior and peer preferences were measured as part of the Biographic Questionnaire on Transsexualism . The total sample of N=634 participants was collected between 2006 and 2012. Participants were prescribed a diagnosis according to DSM-IV-TR criteria of Gender Identity Disorder . The results show, that cross-gender behavior was more frequently recalled in FtMS than MtFs. Within the gender-groups, individuals who were assessed as having an early onset recalled cross-gender behaviors more frequently than individuals who were assessed as having a late-onset. The results will be discussed in line with actual research findings.