A Cross-Sectional Multicenter Study of Multidimensional Body Image in Adolescents and Adults with Gender Dysphoria Before and After Transition-Related Medical Interventions
Persistent feelings of gender dysphoria (GD) are accompanied by distress and body dissatisfaction in most clinically referred adolescents and adults. Transition-related medical interventions (e.g., puberty suppression, hormones, or surgery) may alleviate body dissatisfaction. The aim of the present cross-sectional study was to compare multidimensional body image across clinically referred adolescents and adults undergoing different transition-related medical interventions. Two clinical samples of adolescents (n = 82) and adults (n = 120) referred to specialized departments of four different transgender health services in Germany participated in the study. In total, 202 individuals from the female-to-male (FtM individuals) and male-to-female (MtF individuals) spectrum aged 14–74 years were included at different stages of their transition. Four scales assessing multidimensional aspects of body image (measured by the Body Image Assessment Questionnaire, FBeK) were compared across three groups: sample, gender, and medical interventions (while controlling for age and treatment duration). The results indicated less favorable body image scores compared with the norm in both adolescents and adults with GD. Individuals who had undergone transition-related medical interventions presented a significantly better body image on two of the four scales. Differences according to gender and age were also present. These findings suggest that medical interventions, especially gender-affirming hormones and surgery, are generally beneficial to the body image in individuals with GD. However, not all of the less favorable outcomes in multidimensional body image were positively influenced by the treatment conditions and may thus benefit from additional integrative counseling before and during transition.
KeywordsGender dysphoria Transgender Multidimensional body image DSM-5
We thank all the participants who contributed to this study by providing important personal data on many levels. We thank all the clinicians for their contribution to the data collection in the transgender care units and especially for their contributions to the interdisciplinary work group in Hamburg. We also thank Elmar Brähler and Bernhard Strauß for providing the FBeK norm data. Thanks to our student staff for their help with the database. The authors report no conflicts of interest.
Funding for the study was provided to the corresponding author by Hamburg macht Kinder gesund e.V. and FAZIT-Stiftung. The funding source had no involvement in the process of the study’s design, data collection, analysis, or publication.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures in this study were performed in accordance with the ethical standards of the institutional or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- Bandini, E., Fisher, A. D., Castellini, G., Lo Sauro, C., Lelli, L., Meriggiola, M. C., … Ricca, V. (2013). Gender identity disorder and eating disorders: Similarities and differences in terms of body uneasiness. Journal of Sexual Medicine, 10, 1012–1023. https://doi.org/10.1111/jsm.12062.CrossRefPubMedGoogle Scholar
- Becker, I., Nieder, T. O., Cerwenka, S., Briken, P., Kreukels, B. P. C., Cohen-Kettenis, P. T., … Richter-Appelt, H. (2016). Body image in young gender dysphoric adults: A European multi-center study. Archives of Sexual Behavior, 45, 559–574. https://doi.org/10.1007/s10508-015-0527-z.CrossRefPubMedGoogle Scholar
- Cash, T. F., & Pruzinsky, T. (2002). Body image: A handbook of theory, research, and clinical practice. New York: Guilford.Google Scholar
- Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13, 165–232.Google Scholar
- de Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8, 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943.x.CrossRefPubMedGoogle Scholar
- Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57, 144–149. https://doi.org/10.1016/j.jadohealth.2015.03.003.CrossRefPubMedGoogle Scholar
- Jones, B. A., Haycraft, E., Brewin, N., Claes, L., Bouman, W. P., & Arcelus, J. (2018). Risk factors for eating disorder psychopathology within the treatment seeking transgender population: The role of cross-sex hormone treatment. European Eating Disorders Review, 26, 120–128. https://doi.org/10.1002/erv.2576.CrossRefPubMedGoogle Scholar
- Kessler, S. J., & McKenna, W. (1978). Gender: An ethnomethodological approach. Chicago: University of Chicago Press.Google Scholar
- Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia: W. B. Saunders.Google Scholar
- Kozee, H. B., Tylka, T. L., & Bauerband, L. A. (2012). Measuring transgender individuals’ comfort with gender identity and appearance: Development and validation of the Transgender Congruence Scale. Psychology of Women Quarterly, 36, 179–196. https://doi.org/10.1177/0361684312442161.CrossRefGoogle Scholar
- Lawrence, A. A., & Zucker, K. J. (2012). Gender identity disorders. In M. Hersen & D. C. Beidel (Eds.), Adult psychopathology and diagnosis (6th ed., pp. 601–635). Hoboken, NJ: Wiley.Google Scholar
- Muth, J. L., & Cash, T. F. (1997). Body-image attitudes: What difference does gender make? Journal of Applied Social Psychology, 27, 1438–1452. https://doi.org/10.1111/j.1559-1816.1997.tb01607.x.CrossRefGoogle Scholar
- Nieder, T. O., Herff, M., Cerwenka, S., Preuss, W. F., Cohen-Kettenis, P. T., De Cuypere, G., & Richter-Appelt, H. (2011). Age of onset and sexual orientation in transsexual males and females. Journal of Sexual Medicine, 8, 783–791. https://doi.org/10.1111/j.1743-6109.2010.02142.x.CrossRefPubMedGoogle Scholar
- Röder, M., Barkmann, C., Richter-Appelt, H., Schulte-Markwort, M., Ravens-Sieberer, U., & Becker, I. (2018). Health related quality of life in transgender adolescents: Associations with body image and emotional and behavioral problems. International Journal of Transgenderism, 19, 78–91. https://doi.org/10.1080/15532739.2018.1425649.CrossRefGoogle Scholar
- Smolak, L., & Cash, T. (2011). Future challenges for body image science, practice, and prevention. In T. F. Cash & L. Smolak (Eds.), Body image: A handbook of theory, research, and clinical practice (2nd rev ed., pp. 471–478). New York: Guilford Press.Google Scholar
- Steensma, T. D., McGuire, J. K., Kreukels, B. P., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582–590. https://doi.org/10.1016/j.jaac.2013.03.016.CrossRefPubMedGoogle Scholar
- Strauß, B., & Appelt, H. (1983). Ein Fragebogen zur Beurteilung des eigenen Körpers [The Body Experience Questionnaire]. Diagnostica, 29, 145–164.Google Scholar
- Strauß, B., & Richter-Appelt, H. (1996). Fragebogen zur Beurteilung des eigenen Körpers (FBeK), Handanweisung [The Body Image Assessment Questionnaire, Manual]. Göttingen: Hogrefe.Google Scholar
- van de Grift, T. C., Cohen-Kettenis, P. T., Elaut, E., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., & Kreukels, B. P. C. (2016a). A network analysis of body satisfaction of people with gender dysphoria. Body Image, 17, 184–190. https://doi.org/10.1016/j.bodyim.2016.04.002.CrossRefPubMedGoogle Scholar
- van de Grift, T. C., Cohen-Kettenis, P. T., Steensma, T. D., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., & Kreukels, B. P. C. (2016b). Body satisfaction and physical appearance in gender dysphoria. Archives of Sexual Behavior, 45, 575–585. https://doi.org/10.1007/s10508-015-0614-1.CrossRefPubMedGoogle Scholar
- van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., De Cuypere, G., Richter-Appelt, H., & Kreukels, B. P. C. (2017). Effects of medical interventions on gender dysphoria and body image: A follow-up study. Psychological Medicine, 79, 815–823. https://doi.org/10.1097/PSY.0000000000000465.Google Scholar
- van de Grift, T. C., Kreukels, B. P. C., Elfering, L., Özer, M., Bouman, M., Buncamper, M. E., & Mullender, M. G. (2016c). Body image in Transmen: Multidimensional measurement and the effects of mastectomy. Journal of Sexual Medicine, 13, 1778–1786. https://doi.org/10.1016/j.jsxm.2016.09.003.CrossRefPubMedGoogle Scholar
- Witcomb, G. L., Bouman, W. P., Brewin, N., Richards, C., Fernandez-Aranda, F., & Arcelus, J. (2015). Body image dissatisfaction and eating-related psychopathology in trans individuals: A matched control study. European Eating Disorders Review, 23, 287–293. https://doi.org/10.1002/erv.2362.CrossRefPubMedGoogle Scholar