Background

Introduction

“My roommate is having problems.”

“Problems?” I asked. “What kind of problems?”

My host told the long story about his roommate as succinctly as possible. Another transman like the two of us, he had suffered an abusive childhood and stays in mental institutions. He was delusional again, and afraid to go to the hospital for treatment.

In the morning, while cooking eggs for the family of genderqueers who shared the apartment, I talked with the scared boy who was sometimes lucid, sometimes off on a tangent or uttering non sequiturs. The last time he’d been in a mental hospital, he told me, they’d made him dress like a woman, called him by his old name, and used female pronouns. He had also been sexually assaulted while institutionalized.

Like taking a dose of penicillin, he seemed to regard going to the mental hospital as a place where they would kill anything that looked like a delusion, including his own sense of being a man.

What is gender?

Stoller describes gender as “A complex system of beliefs about oneself: a sense of one’s masculinity and femininity. It implies nothing about the origins of that sense (e.g. whether the person is male or female). It has, then, psychological connotations only: one’s subjective state.”(21)

Why is mental illness a particular concern to trans community?

Assumptions that trans people are necessarily mentally ill create discriminatory policies in access to physical and mental health care as well as in access to employment, housing, and other civil matters.

Discrimination and powerful gender policing in society creates anxiety and fear in gender dysphoric people, adding to their mental health burdens and increasing incidence of substance abuse and suicide.

Mental illness is used to exclude self-identified transsexuals from gender identity programs.

Research on co-morbid mental illness in self-identified transsexuals is used to create more restrictive criteria for gender programs.

Criteria for diagnosis of gender identity disorders from the DSM-IV

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children the disturbance is manifested by four (or more) of the following:

  • Repeatedly stated desire to be, or insistence that he/she is, the other sex;
  • In boys, preference for cross-dressing or simulating female attire; in girls, insistence on only wearing stereotypical masculine clothing;
  • Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex;
  • Intense desire to participate in the stereo-typical games and pastimes of the other sex;
  • Strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as:

  • stated desire to be the other sex;
  • frequent passing as the other sex;
  • desire to live and be treated as the other sex;
  • conviction that he/she has the typical feelings and reactions of the other sex

B. Persistent discomfort with his/her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys: the assertion that their penis and testes are disgusting or will disappear, or assertion that it would be better not to have a penis, or aversion towards rough-and-tumble play and rejection of male stereotypical toys, games and activities; in girls, the rejection of urinating in a sitting position, assertion that they have or will grow a penis, or assertion that they do not want to grow breasts or menstruate, or marked aversion towards normative female clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g. request for hormones, surgery or other procedures to physically alter sexual characteristics or to simulate the other sex) or belief that they were born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. (2)

Mental Illness Linked to Trans ID/GID

Personality traits links

“…it is not clear if transsexuals have different personality traits than that of nontranssexual groups.” —Wolfradt & Neumann (26)

Much research has been devoted to finding personality traits common to children, mainly boys, referred for gender problems. A few studies have concluded that there is high rate of separation anxiety and internalizing difficulties among boys with gender issues. A study employing the Childhood Behavior Check List indicates that psychopathology increases with age. The study’s authors attribute this to the impact of social ostracism, and correlate it with the mental health of the mothers of the boys. (27)

Research on trans women indicate “high threshold values for perception, lack of emotional expressions including a difficulty in perceiving the aggressive part of the stimulus picture, and some projection and introjection responses.” (22) (23) MTFs score higher than either males or females on self esteem and dynamic body image, and describe themselves as more feminine. (26) They also describe themselves as being more feminine than homosexual males did. (17)

FTMs tend to have better social, psychological, and psychiatric outcome of sex reassignment than MTFs, and better relationships with partners and siblings, despite better surgical results for MTFs. According to one study following up on gender clinic clients five years after beginning transition, MTFs and FTMs are equally well socially integrated, and their MMPI scores remained unchanged at follow-up after five years, suggesting that their personalities are not markedly changed by transition. (3)

Mental health issues caused by being trans

Suicide attempts

In the same study, twelve percent of MTFs and 21% of FTMs had attempted suicide prior to entering treatment. Further questioning revealed that in virtually all of these cases the behavior was attributed to intense frustration and exasperation over the gender dysphoric condition. They reached a breaking point, felt isolated, unable to talk to others, were rejected by family or an intimate partner, or were disgusted with their anatomic state and felt they couldn’t change. All of the attempts occurred prior to becoming involved in gender treatment, and none had an attempt since beginning therapy for gender issues. (5)

Substance abuse

Although no study I’ve read has formally linked it to the stress of living with gender dysphoria, it stands to reason that, like suicide attempts, substance abuse is an escape from the pain and loneliness of living with a stigmatized condition. Twenty-nine percent of MTFs and 26% of FTMs had substance abuse problems prior to entering treatment for gender issues (5)

Anorexia Nervosa

Despite much anecdotal evidence of anorexia nervosa among MTFs, I was unable to find much in the medical literature reporting on trans women with this illness. A case report of a 24 year old post-op FTM developing anorexia nervosa with purging after SRS. The patient reported wanting to be thinner to avoid feminine traits in his body shape. This patient was also alcoholic and had both major depression and borderline personality disorder. (10) One retrospective study of twenty-eight trans people reported cases of anorexia nervosa prior to transition. (20)

Dissociation

Dissociation is “a persistent or recurrent feeling of being detached from one’s mental processes or body” (2) In a 1997 study, ten percent of transsexuals had high dissociation scores, indicating the possibility of significant dissociative disorders. (14) These results were explained by emphasizing the importance of dissociative experiences in coping with gender dysphoria. (25)

Depersonalization

According to a study published in Archives of Sexual Behavior last year, depersonalization, or a feeling of unreality or detachment from one’s body, decreases in post-operative MTF transsexuals because the discrepancy between perceived body image and gender role is reduced. When it functions as a defense mechanism and the origin of the discrepancy is removed, the defense mechanism is no longer needed. The same study suggests that post-operatively the focus MTFs have on bodily sensations is more like that of men— in other words, more intense— than the relatively weaker concentration on bodily sensation— and more negative body image— of women. (26)

Mental Illnesses mimicking GID

Counter-Phobic Response and the Snow White Syndrome

Termed “Snow White Syndrome,” a Belgian study published this year used the Rorschach to determine that fully one third of participants were very passive, which they took as proof of their theory that transsexuality is a counter-phobic response to the fear of castration. “These transsexuals appear to shy away from the difficulties of life by seeking refuge into a world of fantasy, which they fill with the representations borrowed from reality (rather than fantasy) and consequently that are liable to be transposed, if necessary, back into reality.” (19)

Schizophrenia and Racist Assumptions

Much has been made of the link between the delusions experienced by 15-20% of schizophrenics of being the opposite sex (16) and gender identity disorder. However, the two are easily enough distinguished by trained professionals: schizophrenics do not self-identify as transsexuals or request sex change (16) . A case study of a Maori woman with paranoid schizophrenia illustrates the difference between transvestism, which she displays while well, and her delusions about transforming into a man while having a psychotic episode.(18) Despite the apparently ease with which delusions may be distinguished from GID, medical professionals working in gender clinics continue to advocate for lengthy monitoring prior to surgery to rule out schizophrenic delusions that appear to be gender dysphoric. (4)

Perhaps more important than the prejudicial assumptions that all trans people may be suffering from schizophrenic delusions are the racist assumptions made in some of the medical literature. Data from nine gender clinics in the US show that of 281 female SRS applicants, 93.6% were white and 6.4% black. (The study did not give statistics on any other racial or ethnic groups.) This data suggests that black people and particularly black females are underrepresented in gender programs. (16)

Case Western Reserve University Gender Identity Clinic has had only five black female applicants for transsexual evaluation, and all were seriously psychopathological: three were schizophrenic, one was described as having “schizophrenic character,” and one was described as having “psychotic character” or borderline personality. Four were victims of incest, one had never had sex, and others had had sex by as early as five years old, all with females. Two had otherwise been abused, two had been in jail, and two had been psychiatrically hospitalized. Several were on pysch meds, and all had either overt or subintentional suicidal behavior. One had been shot in the head at age 19. The study mentioned that one of the patients described herself as being raised “like a boy” by her grandmother, while another claimed to have been hated by her mother for being a girl, and another fantasized she had a penis growing out of her navel. The clinic at which the patients were seen is near very “economically deprived and socially explosive” urban area. (16)

Pyschological tests, including the TAT and WAIS, found violence, envy, separation, loss, abandonment, gender confusion, sadomasochistic relationships, intense confusion in response to aggression, low-average cognitive function, “idiosyncratic and bizarre thinking”, ego defects, and psychotic traits among the five patients.

Based on these five patients, the study suggests that because black women are more masculine and aggressive they are “inoculated” against gender identity disorder except in cases of psychopathology. “…[T]here probably are some black females who are nonpsychotic (and nonschizophrenic) who would request SRS. We have simply not seen any.”

Extreme dissociative response to severe child abuse

Devor found that 60% of FTMs reported severe child abuse. This number is higher than the 27% reported by women in an adult retrospective study. (11) Based on this study of 45 transmen, Devor claims transsexualism may be an adaptive extreme dissociative survival response to severe child abuse.(7)

OCD with Transvestism

In a large scale study of 1,032 cross-dressers, only 5% were “transsexually inclined.”(9) Two case studies of patients with OCD and transvestism (DSM-IV) illustrate possible differences between transvestism as a symptom of OCD (i.e. responds to medication) and OCD and GID co-morbidity. The authors of a study published last year hypothesize that OCD could be symptom of transvestism, or vice versa. (1)

Neurological dysfunction

There are “patchy and inconsistent” links between fetishistic behavior, including transvestitism, and neurological dysfunction such as epilepsy.

Access To and Success With Transition

Ability to self-select for SRS

Opinions, even in the medical community, are slowly changing to accept trans people’s rights to self-determination. Statistically, 80% of patients are satisfied with the results of their physical transitions, and only 2% regret their decision. (23) The low incidence of negative results; combined with the very high rates of substance abuse and suicide, and poor mental health of trans people who are not living in the gender of their preference, the medical community’s priority should be on granting greater rather than more limited access to transition.

In Richard Green’s presidential address to the Harry Benjamin society, he says “[F]rom the perspective of John Stuart Mill, the original civil libertarian, it should be irrelevant whatever the basis of same-sex attraction or wish to be the other sex, providing this is not harmful to another.” (12) An ethnographic study of trans people who created their own transition resources outside of gender clinics suggests “subjects were in general quite capable of deciding what medical technologies they would utilize, and when, and of making their own decisions about gender-role transition.”(6)

Mental illness in GID patients

Of 435 gender dysphoric individuals (318 male, 117 female), 9% had problems with mental illness. The incidence is similar to that seen in the general population. Results support the view that transsexualism is usually an isolated diagnosis and not part of any general psychopathological disorder. (5)

Bizarre factoid: The number of patients with additional psychiatric diagnoses tended to live closest to the gender clinic, suggesting either that only the most functional could manage to travel upwards of 300 miles to the gender clinic, or that living near a gender clinic is enough to make you crazy. (The first assumption is theirs, the second is mine.) (5)

In a 1981 study, male patients applying for treatment in gender program who live as women were generally no more mentally ill than the general population, but those living as men were as disturbed as the psychiatric patients used as a control.(13)

Mental health at follow-up

A study on body-image, self-esteem and depersonalization in 30 post-operative transwomen who’ve also had vocal surgery found that that they had better self-esteem and body image, were healthily androgynous, and satisfied with their lives. The study pointed out that having many masculine and feminine traits better equips a person to deal with a variety of situations in their personal lives. (26)

In a 1996 study, of 19 transsexuals at five-year follow-up, 68% had improved in at least two areas of social, psychological, and psychiatric functioning, three judged their outcome as unsatisfactory, three were unchanged, and one regretted the decision to transition. (3)

Mental health factors in successful transition

Factors predicting positive outcome [include] “ability to achieve a satisfactory sex life without functional genitalia.”

 

Risk factors identified with poor transition outcome in a 1996 survey of MTFs and FTMs are gender dysphoric transvestism, personality disorders, lack of social and psychological support, and surgical shortcomings and complications. (3) A 1978 study also identified older age at onset and inappropriate physical build as risk factors in MTFs, a theory that has not been upheld by more current studies. Factors predicting positive outcome are supposed by Bodlund and Kullgren to be female sex— FTMs have a nonsignificant tendency toward more positive outcomes than MTFs, explained by the fact that “Biological women are more successful in areas of partnership and work ability,” early debut (not statistically significant), high level of social functioning before surgery, personal stability, restricted inclusion criteria in gender programs, supportive programs, quality of partnerships, and (another bizarre factoid) “ability to achieve a satisfactory sex life without functional genitalia.” Initial mental health test scores on Axis I and V also not statistically significant in predicting positive outcome. However, Axis II criteria are significantly predictive, particularly personality disorder. Transsexuals who are improved five years after beginning transition have more subthreshold antisocial traits. According to the authors of the study, “Perhaps being somewhat antisocial facilitates adaptation in the new gender role.” (3)

Axis I – major disorders
Axis II – personality disorders
Axis III – related physical health problems
Axis IV – problems in social environment
Axis V – current level of functioning

Conclusion

If we’re nuts, it’s in response to social stigmas, lack of resources for transition, and a lack of medical and surgical expertise to carry out our physical transitions.

Recommendations

Work against discrimination

DiCeglie: “Breaking a cycle of secrecy by promoting openness and creating the conditions for the tolerance of confusion and uncertainty are important issues in the management of gender identity disorders.”(8)

Create resources and access to transition

Bodlund and Kullgren, after evaluating predictive factors in a positive outcome from gender reassignment, concentrated on ways to restrict access to gender programs rather than on how to best help those who do not have positive outcomes. (3) Many of the risk factors identified, such as personal stability and social function, can be alleviated with support systems and talk therapy. People who self-identify as trans need better psychiatric resources; if possible, atypical gender dysphorics should have access to a treatment modality that will give them a positive outcome.

Improve surgical outcomes of GRS

Some of the negative outcomes of GRS are caused by poor surgery, particularly for FTMs.

Provide trans-sensitive mental health resources

There are some writings available on creating trans-sensitive substance abuse programs. (15) (24) However, there is still a very high need for more mental health resources for trans people. As in the story that begins this article, no one should have to choose between mental health care and maintaining dignity in one’s gender identity.

Consciousness raising

Being aware of the dangers of attempting to emulate a stereotype, and the reality that having both masculine and feminine qualities makes one better prepared for all of the challenges of living, makes not only a better transsexual, but a better trans activist. (Who says we don’t recruit?) Trans people who are truly not conscious of the unreality of their feminine or masculine ideals, who have not made themselves into students of gender performance, and who are unaware of feminist issues such as the glass ceiling, sexual harassment, and male bonding will be unprepared for the reality that awaits them. In addition to studying the medical literature, we should be studying gender theory.

Works Cited

Abdo CHN, Hounie A, Scanavino M de T, Miguel EC. (2001). OCD and transvestism: is there a relationship? Acta Psychiatr Scand. 103:471-473.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IV). Washington DC: APA.

Bodlund O, Kullgren G. (1996). Transsexualism—general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex. Arch Sex Behav 1996 Jun;25(3):303-16.

Bower H. (2001) The gender identity disorder in the DSM-IV classification: a critical evaluation. Aust N Z J Psychiatry 2001 Feb;35(1):1-8.

Cole CM, O’Boyle M, Emory LE, Meyer WJ 3rd. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Arch Sex Behav 1997 Feb;26(1):13-26.

Denny D, Bolin A. And now for something completely different: An outcome study with surprising results and important implications. [Abstract] Int J Transgenderism. Abstract available online at http://www.symposion.com/ijt/hbigda/vancouver/denny2.htm.

Devor H. (1994). Transsexualism, dissociation, and child abuse. An initial discussion based on non-clinical data. J. Psychol. Hum. Sex. 6:49-72.

Di Ceglie D. (2000). Gender identity disorder in young people. Advances in Psychiatric Treatment. 6:458-466.

Docter RF & Prince V. (1997). Transvestism: a survey of 1032 cross-dressers. Arch Sex Behav. 6:589-605.

Fernández-Aranda F, Peri JP, Navarro V, Badía-Casanovas A, Turón-Gil V, Vallejo-Ruiloba J. (2000). Transsexualism and anorexia nervosa: a case report. Eating Disorders Spring 8(1):63-67.

Finkelhor, D., Hotaling, G., Lewis, I. A. & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse & Neglect, 14, 19-28.

Green, Richard. (1999). Reflections on “Transsexualism and Sex Reassignment” 1969-1999: Presidential Address, August 1999. XVI Harry Benjamin International Gender Dysphoria Association Symposium 17 – 21 August 1999, London. Retrieved March 12, 2002 from http://www.symposion.com/ijt/greenpresidental/green00.htm.

Greenberg RP, Laurence L. (1981). A comparison of the MMPI results for psychiatric patients and male applicants for transsexual surgery. J Nervous and Mental Disease. 169:5:320-323.

Hartmann U, Becker H, & Rueffer-Hesse C. (1997). Self and gender: narcissistic pathology and personality factors in gender dysphoric patients. Preliminary results of a prospective study. Int J Transg. 1:http://www.symposion.com/ijt/ijtc0103.htm.

Lombardi EL, van Servellen G. (2000). Building culturally sensitive substance use programs for transgendered populations. J Subst Abuse Treat. 19(3):291-6

Lothstein LM, Roback H. (1984). Black female transsexuals and schizophrenia: a serendipitous finding? Arch Sex Behav. 13:4:371-386.

Lutz DJ, Roback HB, Hart M. (1984). Feminine gender identity and psychological adjustment of male transsexuals and male homosexuals. J. Sex. Res. 20: 350-362.

Manderson L, Kumar S. (2001) Gender identity disorder as a rare manifestation of schizophrenia. Aust N Z J Psychiatry 2001 Aug;35(4):546-7.

Michel A, Mormont C. (2002). Was Snow White a transsexual? Universite de Liege, Service de Psychologie clinique, boulevard du Rectorat, B 33, 4000 Liege, Belgique. Encephale Jan-Feb;28(1):59-64.

O’Gorman EC. (1982). A retrospective study of epidemiological and clinical aspects of 28 transsexual patients. Arch Sex Behav. 11:231-236.

Stoller R. (1992) Gender identity development and prognosis: a summary. In New Approaches to Mental Health from Birth to Adolescence (eds C Chiland & J G Young),pp.78-87. New Haven, CT: Yale University Press.

Sundbom E, Bodlund O, Höjerback T. (1995). Object relations and defensive operations in transsexuals and borderline patients as measured by the Defense Mechanism Test. Nordic J Psychiatry. 49: 379-388.

Sundbom E, Bodlund O. (1999). Prediction of outcome in transsexualism by means of the defense mechanism test and multivariate modeling: a pilot study. Perceptual and Motor Skills. 88:3-20.

Transgender protocol: treatment services guidelines for substance abuse treatment providers. (1995). San Francisco, CA: Transgender Substance Abuse Treatment Policy Group, San Francisco Lesbian, Gay, Bisexual, Transgender Substance Abuse Task Force.

Walling, DP, Goodwin JM, Cole CM. (1998). Dissociation in a transsexual population. J. Sex. Edu. Thera. 23:121-123.

Wolfradt U, Neumann K. (2001 Jun). Depersonalization, self-esteem and body image in male-to-female transsexuals compared to male and female controls. Arch Sex Behav Jun;30(3):301-10.

Zucker KJ, Bradley SJ. (1999). Gender identity disorder and transvestic fetishism. In Child and Adolescent Psychological Disorders: A Comprehensive Textbook. Netherton SD, Holmes D, Walker CE Eds. New York: Oxford University Press.