Abstract
Body dissatisfaction plays an important role in the development of psychiatric problems such as eating disorders as well as gender dysphoria (GD). Cross-sex hormonal treatment (CHT) alleviates the dissatisfaction by making various changes in the body. We examined the alteration of body uneasiness, eating attitudes and behaviors, and psychological symptoms longitudinally in Turkish participants with female-to-male gender dysphoria (FtM GD) after CHT. Thirty-seven participants with FtM GD and 40 female controls were asked to complete the Body Uneasiness Test to explore different areas of body-related psychopathology, the Eating Attitudes Test to assess eating disturbances, and the Symptom Checklist-90 Revised to measure psychological state, both before CHT and after 6 months of CHT administration. The baseline mean body weight, BMI scores, body uneasiness scores, and general psychopathological symptoms of participants with FtM GD were significantly higher than female controls, whereas baseline eating attitudes and behaviors were not significantly different. Over time, FtM GD participants’ mean body weight and BMI scores increased, body uneasiness and general psychopathological symptoms decreased, and eating attitudes and behaviors had not changed at 24th weeks following CHT administration compared to baseline. CHT may have a positive impact on body uneasiness and general psychopathological symptoms in participants with FtM GD. However, CHT does not have an impact on eating attitudes and behaviors.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
a Campo, J., Nijman, H., Merckelbach, H., & Evers, C. (2003). Psychiatric comorbidity of gender identity disorders: A survey among Dutch psychiatrists. American Journal of Psychiatry, 160, 1332–1336. https://doi.org/10.1176/appi.ajp.160.7.1332.
Ålgars, M., Alanko, K., Santtila, P., & Sandnabba, N. K. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders: The Journal of Treatment & Prevention, 20, 300–311. https://doi.org/10.1080/10640266.2012.668482.
Ålgars, M., Santtila, P., & Sandnabba, N. K. (2010). Conflicted gender identity, body dissatisfaction, and disordered eating in adult men and women. Sex Roles, 63, 118–125. https://doi.org/10.1007/s11199-010-9758-6.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
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.
Bassil, N., Alkaade, S., & Morley, J. E. (2009). The benefits and risks of testosterone replacement therapy: A review. Therapeutics and Clinical Risk Management, 5, 427–448.
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.
Blaak, E. (2001). Gender differences in fat metabolism. Current Opinion in Clinical Nutrition and Metabolic Care, 4, 499–502.
Cash, T. F., Ancis, J. R., & Strachan, M. D. (1997). Gender attitudes, feminist identity, and body images among college women. Sex Roles, 36, 433–447. https://doi.org/10.1007/BF02766682.
Cella, S., Iannaccone, M., & Cotrufo, P. (2013). Influence of gender role orientation (masculinity versus femininity) on body satisfaction and eating attitudes in homosexuals, heterosexuals and transsexuals. Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity, 18, 115–124. https://doi.org/10.1007/s40519-013-0017-z.
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. https://doi.org/10.1080/15532739.2011.700873.
Colizzi, M., Costa, R., Pace, V., & Todarello, O. (2013). Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. Journal of Sexual Medicine, 10, 3049–3058. https://doi.org/10.1111/jsm.12155.
Colizzi, M., Costa, R., Scaramuzzi, F., Palumbo, C., Tyropani, M., Pace, V., … Todarello, O. (2015a). Concomitant psychiatric problems and hormonal treatment induced metabolic syndrome in gender dysphoria individuals: A 2 year follow-up study. Journal of Psychosomatic Research, 78, 399–406. https://doi.org/10.1016/j.jpsychores.2015.02.001.
Colizzi, M., Costa, R., & Todarello, O. (2014). Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study. Psychoneuroendocrinology, 39, 65–73. https://doi.org/10.1016/j.psyneuen.2013.09.029.
Colizzi, M., Costa, R., & Todarello, O. (2015b). Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real? Psychiatry Research, 226, 173–180. https://doi.org/10.1016/j.psychres.2014.12.045.
Corona, G., Rastrelli, G., Monami, M., Saad, F., Luconi, M., Lucchese, M., … Maggi, M. (2013). Body weight loss reverts obesity associated hypogonadotropic hypogonadism: A systematic review and metaanalysis. European Journal of Endocrinology, 168, 829–843. https://doi.org/10.1530/EJE-12-0955.
Costantino, A., Cerpolini, S., Alvisi, S., Morselli, P. G., Venturoli, S., & Meriggiola, M. C. (2013). A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex and Marital Therapy, 39, 321–335. https://doi.org/10.1080/0092623X.2012.736920.
Couturier, J., Pindiprolu, B., Findlay, S., & Johnson, N. (2015). Anorexia nervosa and gender dysphoria in two adolescents. International Journal of Eating Disorders, 48, 151–155. https://doi.org/10.1002/eat.22368.
Cuzzolaro, M., Vetrone, G., Marano, G., & Garfinkel, P. E. (2006). The Body Uneasiness Test (BUT): Development and validation of a new body image assessment scale. Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity, 11, 1–13. https://doi.org/10.1007/BF03327738.
Dağ, İ. (1991). Belirti Tarama Listesi (SCL-90-R)’nin üniversite öğrencileri için güvenirliği ve geçerliği [Symptom Check List (SCL 90-R): A reliability and validity study]. Turkish Journal of Psychiatry, 2, 5–12.
Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, 280–289. https://doi.org/10.1192/bjp.128.3.280.
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.
Elbers, J. M. H., Asscheman, H., Seidell, J. C., & Gooren, L. J. G. (1999). Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals. American Journal of Physiology-Endocrinology and Metabolism, 276, E317–E325.
Elbers, J. M. H., Asscheman, H., Seidell, J. C., Megens, J. A. J., & Gooren, L. J. G. (1997). Long-term testosterone administration increases visceral fat in female to male transsexuals. Journal of Clinical Endocrinology and Metabolism, 82, 2044–2047. https://doi.org/10.1210/jcem.82.7.4078.
Ewan, L. A., Middleman, A. B., & Feldmann, J. (2014). Treatment of anorexia nervosa in the context of transsexuality: A case report. International Journal of Eating Disorders, 47, 112–115. https://doi.org/10.1002/eat.22209.
Feder, S., Isserlin, L., Seale, E., Hammond, N., & Norris, M. L. (2017). Exploring the association between eating disorders and gender dysphoria in youth. Eating Disorders, 25, 310–317. https://doi.org/10.1080/10640266.2017.1297112.
Fernández-Aranda, F., Peri, J. M., Navarro, V., Badia-Casanovas, A., Turón-Gil, V., & Vallejo-Ruiloba, J. (2000). Transsexualism and anorexia nervosa: A case report. Eating Disorders: The Journal of Treatment & Prevention, 8, 63–66. https://doi.org/10.1080/10640260008251212.
Fisher, A. D., Bandini, E., Casale, H., Ferruccio, N., Meriggiola, M. C., Gualerzi, A., … Maggi, M. (2013). Sociodemographic and clinical features of gender identity disorder: An Italian multicentric evaluation. Journal of Sexual Medicine, 10, 408–419. https://doi.org/10.1111/j.1743-6109.2012.03006.x.
Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., Benni, L., … Rellini, A. H. (2014). Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria. Journal of Sexual Medicine, 11, 709–719. https://doi.org/10.1111/jsm.12413.
Fisher, A. D., Castellini, G., Ristori, J., Casale, H., Cassioli, E., Sensi, C., … Maggi, M. (2016). Cross-sex hormone treatment and psychobiological changes in transsexual persons: Two-year follow-up data. Journal of Clinical Endocrinology and Metabolism, 101, 4260–4269. https://doi.org/10.1210/jc.2016-1276.
Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273–279.
Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871–878. https://doi.org/10.1017/S0033291700049163.
Gómez-Gil, E., Zubiaurre-Elorza, L., Esteva, I., Guillamon, A., Godás, T., Almaraz, M. C., … Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology, 37, 662–670. https://doi.org/10.1016/j.psyneuen.2011.08.010.
Gooren, L. J. (2005). Hormone treatment of the adult transsexual patient. Hormone Research in Paediatrics, 64, 31–36. https://doi.org/10.1159/000087751.
Gooren, L. J., Giltay, E. J., & Bunck, M. C. (2008). Long-term treatment of transsexuals with cross-sex hormones: Extensive personal experience. Journal of Clinical Endocrinology and Metabolism, 93, 19–25. https://doi.org/10.1210/jc.2007-1809.
Gooren, L. J., Wierckx, K., & Giltay, E. J. (2014). Cardiovascular disease in transsexual persons treated with cross-sex hormones: Reversal of the traditional sex difference in cardiovascular disease pattern. European Journal of Endocrinology, 170, 809–819. https://doi.org/10.1530/EJE-14-0011.
Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Penochet, J.-C., Pringuey, D., … Auquier, P. (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease, 201, 996–1000. https://doi.org/10.1097/NMD.0000000000000046.
Harman, S. M., & Blackman, M. R. (2003). The effects of growth hormone and sex steroid on lean body mass, fat mass, muscle strength, cardiovascular endurance and adverse events in healthy elderly women and men. Hormone Research in Paediatrics, 60, 121–124. https://doi.org/10.1159/000071236.
Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W. J., Spack, N. P., III, … Montori, W. M. (2009). Endocrine treatment of transsexual persons: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism, 94, 3132–3154. https://doi.org/10.1210/jc.2009-0345.
Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, A. (2005). Psychiatric comorbidity in gender identity disorder. Journal of Psychosomatic Research, 58, 259–261. https://doi.org/10.1016/j.jpsychores.2004.08.010.
Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32, 473–478. https://doi.org/10.1002/eat.10090.
Hepp, U., Milos, G., & Braun-Scharm, H. (2004). Gender identity disorder and anorexia nervosa in male monozygotic twins. International Journal of Eating Disorders, 35, 239–243. https://doi.org/10.1002/eat.10247.
Heylens, G., Elaut, E., Kreukels, B. P., Paap, M. C. S., Cerwenka, S., Richter-Appelt, H., … De Cuypere, G. (2014a). Psychiatric characteristics in transsexual individuals: Multicentre study in four European countries. British Journal of Psychiatry, 204, 151–156. https://doi.org/10.1192/bjp.bp.112.121954.
Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014b). Effects of different steps in gender reassignment therapy on psychopathology: A prospective study of persons with a gender identity disorder. Journal of Sexual Medicine, 11, 119–126. https://doi.org/10.1111/jsm.12363.
Jones, B. A., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry, 28, 81–94. https://doi.org/10.3109/09540261.2015.1089217.
Kanayama, G., Amiaz, R., Seidman, S., & Pope, H. G. (2007). Testosterone supplementation for depressed men: Current research and suggested treatment guidelines. Experimental and Clinical Psychopharmacology, 15, 529–538. https://doi.org/10.1037/1064-1297.15.6.529.
Kersting, A., Reutemann, M., Gast, U., Ohrmann, P., Suslow, T., Michael, N., & Arolt, V. (2003). Dissociative disorders and traumatic childhood experiences in transsexuals. Journal of Nervous and Mental Disease, 191, 182–189.
Khoosal, D., Langham, C., Palmer, B., Terry, T., & Minajagi, M. (2009). Features of eating disorder among male-to-female transsexuals. Sexual and Relationship Therapy, 24, 217–229. https://doi.org/10.1080/14681990903082161.
Klein, C., & Gorzalka, B. B. (2009). Sexual functioning in transsexuals following hormone therapy and genital surgery: A review. Journal of Sexual Medicine, 6, 2922–2939. https://doi.org/10.1111/j.1743-6109.2009.01370.x.
Klemchuck, H. P., Hutchinson, C. B., & Frank, R. I. (1990). Body dissatisfaction and eating-related problems on the college campus: Usefulness of the Eating Disorder Inventory with a nonclinical population. Journal of Counseling Psychology, 37, 297–305. https://doi.org/10.1037/0022-0167.37.3.297.
Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology, 41, 96–100. https://doi.org/10.1159/000111554.
Kuiper, B., & Cohen-Kettenis, P. (1988). Sex reassignment surgery: A study of 141 Dutch transsexuals. Archives of Sexual Behavior, 17, 439–457. https://doi.org/10.1007/BF01542484.
Lindgren, T. W., & Pauly, I. B. (1975). A body image scale for evaluating transsexuals. Archives of Sexual Behavior, 4, 639–656.
McHenry, J., Carrier, N., Hull, E., & Kabbaj, M. (2014). Sex differences in anxiety and depression: Role of testosterone. Frontiers in Neuroendocrinology, 35, 42–57. https://doi.org/10.1016/j.yfrne.2013.09.001.
Pauly, I. B., & Lindgren, T. W. (1976–1977). Body image and gender identity. Journal of Homosexuality, 2, 133–142.
Pope, H. G., Jr., Cohane, G. H., Kanayama, G., Siegel, A. J., & Hudson, J. I. (2003). Testosterone gel supplementation for men with refractory depression: A randomized, placebo-controlled trial. American Journal of Psychiatry, 160, 105–111. https://doi.org/10.1176/appi.ajp.160.1.105.
Quirós, C., Patrascioiu, I., Mora, M., Aranda, G. B., Hanzu, F. A., Gómez-Gil, E., … Halperin, I. (2015). Effect of cross-sex hormone treatment on cardiovascular risk factors in transsexual individuals: Experience in a specialized unit in Catalonia. Endocrinología y Nutrición, 62, 210–216. https://doi.org/10.1016/j.endonu.2015.02.001.
Savaşır, I., & Erol, N. (1989). Eating attitude test: Anorexia nervosa symptoms index. Journal of Psychology, 7, 19–25.
Shi, H., Seeley, R. J., & Clegg, D. J. (2009). Sexual differences in the control of energy homeostasis. Frontiers in Neuroendocrinology, 30, 396–404. https://doi.org/10.1016/j.yfrne.2009.03.004.
Simon, L., Zsolt, U., Fogd, D., & Czobor, P. (2011). Dysfunctional core beliefs, perceived parenting behavior and psychopathology in gender identity disorder: A comparison of male-to-female, female-to-male transsexual and nontranssexual control subjects. Journal of Behavior Therapy and Experimental Psychiatry, 42, 38–45. https://doi.org/10.1016/j.jbtep.2010.08.004.
Traish, A. M. (2014). Testosterone and weight loss: The evidence. Current opinion in Endocrinology, Diabetes, and Obesity, 21, 313–322. https://doi.org/10.1097/MED.0000000000000086.
Turan, Ş., Aksoy Poyraz, C., & Duran, A. (2015a). Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report. Eating Behaviors, 18, 54–56. https://doi.org/10.1016/j.eatbeh.2015.03.012.
Turan, Ş., Aksoy Poyraz, C., İnce, E., Sakallı Kani, A., Emül, H. M., & Duran, A. (2015b). Sociodemographic and clinical characteristics of transsexual individuals who presented to a psychiatry clinic for sex reassignment surgery. Turkish Journal of Psychiatry, 26, 153–160.
Tylka, T. L. (2004). The relation between body dissatisfaction and eating disorder symptomatology: An analysis of moderating variables. Journal of Counseling Psychology, 51, 178–191. https://doi.org/10.1037/0022-0167.51.2.178.
Van Caenegem, E., Wierckx, K., Taes, Y., Schreiner, T., Vandewalle, S., Toye, K., … T’Sjoen, G. (2015). Body composition, bone turnover, and bone mass in trans men during testosterone treatment: 1-year follow-up data from a prospective case–controlled study (ENIGI). European Journal of Endocrinology, 172, 163–171. https://doi.org/10.1530/EJE-14-0586.
van de Grift, T. C., Cohen-Kettenis, P. T., Elaut, E., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., & Kreukels, B. P. (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.
van de Grift, T. C., Cohen-Kettenis, P. T., Steensma, T. D., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R. H., … 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.
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. Psychosomatic Medicine, 79, 815–823. https://doi.org/10.1097/PSY.0000000000000465.
van de Grift, T. C., Kreukels, B. P., Elfering, L., Özer, M., Bouman, M. B., 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.
Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and body image disturbances in male-to-female and female-to-male transsexuals. Archives of Sexual Behavior, 38, 364–377. https://doi.org/10.1007/s10508-008-9424-z.
Wajchenberg, B. L. (2000). Subcutaneous and visceral adipose tissue: Their relation to the metabolic syndrome. Endocrine Reviews, 21, 697–738.
Wang, C., Alexander, G., Berman, N., Salehian, B., Davidson, T., McDonald, V., … Swerdloff, R. S. (1996). Testosterone replacement therapy improves mood in hypogonadal men—A clinical research center study. Journal of Clinical Endocrinology and Metabolism, 81, 3578–3583. https://doi.org/10.1210/jcem.81.10.8855804#sthash.Wtu6qVce.dpuf.
Wickman, J. (2003). Masculinity and female bodies. NORA: Nordic Journal of Women’s Studies, 11, 40–54. https://doi.org/10.1080/08038740307272.
Wilson, J. D. (1988). Androgen abuse by athletes. Endocrine Reviews, 9, 181–199. https://doi.org/10.1210/edrv-9-2-181#sthash.EqXrOXgu.dpuf.
Winston, A. P., Acharya, S., Chaudhuri, S., & Fellowes, L. (2004). Anorexia nervosa and gender identity disorder in biologic males: A report of two cases. International Journal of Eating Disorders, 36, 109–113. https://doi.org/10.1002/eat.20013.
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.
Wolfradt, U., & Neumann, K. (2001). Depersonalization, self-esteem and body image in male-to-female transsexuals compared to male and female controls. Archives of Sexual Behavior, 30, 301–310. https://doi.org/10.1023/A:1002752214526.
Zucker, K. J., Lawrence, A. A., & Kreukels, B. P. C. (2016). Gender dysphoria in adults. Annual Review of Clinical Psychology, 12, 217–247. https://doi.org/10.1146/annurev-clinpsy-021815-093034.
Acknowledgements
We would like to thank all the people who volunteered to participate in this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study was approved by the ethics committee of the Cerrahpaşa Medical Faculty at Istanbul University.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Turan, Ş., Aksoy Poyraz, C., Usta Sağlam, N.G. et al. Alterations in Body Uneasiness, Eating Attitudes, and Psychopathology Before and After Cross-Sex Hormonal Treatment in Patients with Female-to-Male Gender Dysphoria. Arch Sex Behav 47, 2349–2361 (2018). https://doi.org/10.1007/s10508-018-1189-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10508-018-1189-4