Factors predicting psychiatric co-morbidity in gender-dysphoric adults
Introduction
Gender identity disorder (GID) is characterised by a strong and persistent identification with the opposite sex and discomfort with one’s own sex (American Psychiatric Association, 1994). Compared with many other psychiatric disorders, GID is rare (Roberto, 1983, Landen et al., 1996a, Landen et al., 1996b), but in recent years there has been a marked increase in individuals seeking treatment for GID (Johansson et al., 2010, Zucker and Lawrence, 2009). Of course, it remains unclear whether this represents a true increase in prevalence or simply greater comfort in seeking out clinical care (Zucker and Lawrence, 2009).
Children and adolescents with GID are at high risk for developing psychiatric problems (Wallien et al., 2007, de Vries et al., 2011a), and the lifetime psychiatric co-morbidity in GID persons may be high (Hepp et al., 2005). Moreover, psychiatric co-morbidity and mental instability are reported to be important unfavourable prognostic factors for long-term psychosocial adjustment in GID (Bodlund and Kullgren, 1996, Michel et al., 2002). Although several studies, including ours, on psychiatric co-morbidity in a large number of persons with GID have been reported (Cole et al., 1997, Haraldsen and Dahl, 2000, Hoshiai et al., 2010, de Vries et al., 2011a), there have been no studies in which various risk factors for current psychiatric co-morbidity among GID persons were simultaneously estimated. However, there have been several studies that focussed on sexual attraction and psychological functioning (Smith et al., 2005a, Smith et al., 2005b; De Cuypere et al., 2007; Lawrence, 2010). Homosexual transsexuals functioned better psychologically than non-homosexual transsexuals (Smith et al., 2005b; De Cuypere et al., 2007). After sexual reassignment surgery (SRS), homosexual transsexuals displayed better psychological functioning than their non-homosexual counterparts (Smith et al., 2005a).
In this study, we investigated the relationship between current psychiatric co-morbidity and demographic characteristics of individuals with GID in Japan. Sexual orientation and age of onset are two potential candidates for subtypes of GID in adults (Lawrence, 2010). Therefore, we think these factors should be included as possible risk factors in this study. Other factors might also be of relevance with regard to psychiatric co-morbidity in persons with GID. In the general population, it was found that low educational levels increased the risk of mental disorders in both genders (Chazelle et al., 2011). Further, about one-third of youths treated for school attendance difficulties continued to have serious adjustment problems later in life (Kearney, 2001). Other researchers have found that 30% of youths with school refusal continued to meet criteria for a psychiatric disorder over a 10-year follow-up period (McCune and Hynes, 2005). One of the long-term sequelae of school refusal is an increased risk for psychiatric illness (Bernstein et al., 2001, Flakierska-Praquin et al., 1997). Stressful events in a person’s youth such as the divorce of his/her parents are also associated with psychiatric illness (Sidebotham and Golding, 2001). Therefore, we hypothesised that sexual orientation, age at onset, low educational achievement, school refusal and parental divorce were risk factors for psychiatric co-morbidity among GID individuals.
Many studies of specific characteristics of the GID population have shown that significant gender differences exist among persons with GID (Okabe et al., 2008, Lawrence, 2010, Paap et al., 2011). Okabe et al. reported that many variables such as age at onset, sexual orientation, presence of a steady partner and experience of marriage were different between male-to-female (MtF) and female-to-male (FtM) transsexuals (Okabe et al., 2008). Paap et al. (2011) found that MtFs reported less severe symptoms of GID than FtMs and that the subcriterion of the GID diagnosis, ‘belief of being born the wrong sex’, was not equally relevant for both subgroups. Therefore, it seems likely that different risk factors would be relevant for present psychiatric co-morbidity within the respective groups. Therefore, statistical analyses were conducted separately for MtFs and FtMs.
Section snippets
GID clinic
The GID Clinic at Okayama University Hospital was established in Okayama in 1997. It was the only specialised GID clinic in western Japan that could perform phalloplasty during the study period. Therefore, more FtMs were referred to this GID clinic than MtFs. The GID Clinic has four departments: psychiatry, urology, gynaecology and plastic and reconstructive surgery. Its services include diagnosis, counselling, genetic testing, hormonal therapy, plastic surgery and coordination of social
Demographic characteristics of GID individuals (table 1)
Demographic characteristics of the individuals are shown in Table 1. Age at first consultation, age at onset, level of education, sexual orientation and psychiatric co-morbidity were significantly different between the MtFs and FtMs. Almost all FtMs (194/217, 89.4%) started to feel discomfort with their gender identity before graduation from elementary school. By contrast, about half the MtFs (51/109, 46.8%) started to feel discomfort with their gender identity after graduation from elementary
Psychiatric co-morbidity
First, we compared the results of this study to other studies on psychiatric co-morbidity among GID persons. Haraldsen and Dahl revealed a relatively high co-morbidity rate of axis I disorders (28/86, 33%) among transsexuals who had undergone sex-reassignment surgery (SRS) using a structured clinical interview (Haraldsen and Dahl, 2000), whereas Cole et al. showed a relatively low rate of axis I disorders (23/435, 5%) in persons with gender dysphoria without a structured interview (Cole et al.,
Conclusions
This is the first report to demonstrate a close relationship between patterns of sexual orientation and psychiatric co-morbidity among GID persons. We should pay more attention to psychiatric co-morbidity, especially among GID persons with non-homosexual sexual orientations.
Acknowledgements
We thank Ms. Ogino and Ms. Kanamori for their skillfull assistance on this study. This study is partly supported by a grant from the Zikei Institute of Psychiatry.
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