Eudaimonic Well-Being in Transsexual People, Before and After Gender Confirming Surgery
Gender confirming surgery (GCS) and cross-sex hormones (CSH) are crucial steps in the self-realization of a transsexual individual. However, no study has analyzed the outcome of GCS in a eudaimonic perspective, nor explored eudaimonic well-being before GCS. The study compares the eudaimonic well-being of trans men (N = 56) and women (N = 89) before and after GCS; in the MtF sample, a further comparison was carried out between those who never started any medical intervention and those who were already taking CSH. Finally, the impact of experiences of harassment, discrimination and violence on eudaimonic well-being in the post-surgery sample was explored. All participants completed the Psychological Well-being Scales (Ryff in J Pers Soc Psychol 57:1069–1081, 1989) and, only the post-surgery sample, a questionnaire to assess previous experiences of harassment, discrimination and violence. Both in MtF and FtM participants, those who already received GCS showed higher scores on self-acceptance; in the MtF sample, higher scores were also found on environmental mastery and lower scores on personal growth. The association between experiences of discrimination on well-being was limited and positive, with higher scores in personal growth only in FtM participants who reported being victims of such experiences. Our results suggest that both MtF and FtM transsexuals show higher levels of eudaimonic well-being after GCS.
KeywordsTranssexualism Eudaimonic well-being Gender confirming surgery Gender transition Transphobic violence
Transsexualism,1 conceptualized in DSM 5 (A.P.A. 2013) as Gender Dysphoria (GD), is characterized by a marked incongruence between the individual’s expressed/experienced gender and the gender assigned at birth, causing clinically significant distress or impairment in social, occupational, or other important areas of everyday functioning. People suffering from GD might pursue hormonal and/or surgical treatments in order to realign their experienced gender with physical appearance.
Gender confirming surgery (GCS) is now considered the treatment of choice in extreme cases of GD and its effectiveness is supported by a large number of studies carried out over the last few decades (Gijs and Brewaeys 2007; Selvaggi and Bellringer 2011).
Research in this field has shown that GCS can effectively reduce gender dysphoric feelings, improve subjective well-being (Weyers et al. 2009), quality of life (Lawrence 2003; Wierckx et al. 2011), social and family relations, and that at follow-up clients show overall high satisfaction with their self-image (Weyers et al. 2009), with aesthetic and functional outcome, and improvement in sexual functioning (De Cuypere et al. 2005; Klein and Gorzalka 2009; Wierckx et al. 2011).
Even when exploring well-being as an outcome measure of GCS, these studies have mainly relied on a hedonic perspective; however, the literature on psychological well-being has come to a clear distinction between hedonic and eudaimonic well-being, the former dealing with happiness and satisfaction with life, the latter dealing with human potential and functioning in life (Ryan and Deci 2001). Although associations between hedonic and eudaimonic well-being have been found and described, the two constructs can be considered conceptually related although empirically distinct (Keyes et al. 2002).
The term “eudaimonia”, derived from humanistic and existential perspectives, refers to well-being as distinct from happiness, on the assumption that subjective happiness cannot be sic et simplicter equated with well-being. The eudaimonic perspective on well-being implies living in full accordance with one’s daimon, that is one’s true self. Eudaimonia is then experienced when the individual’s life is most congruent with deeply held values. In such circumstances, people would feel intensely alive and authentic, existing as who they really are (Waterman 1993).
Several theoretical models have been proposed for the concept of eudaimonia (Ryan and Deci 2001) and among them Ryff and Singer (1998, 2000) have conceptualized it in a lifespan theory of human development. The authors propose a definition of psychological well-being as “the striving for perfection that represents the realization of one’s true potential” (Ryff 1995, p. 100). According to Ryff (2014), eudaimonic well-being implies different dimensions of positive functioning including personal growth, purposeful engagement in life, fulfillment of personal talents and capacities and enlightened self-knowledge (Ryff 2014). Accordingly, the multidimensional approach to the measurement of psychological well-being covers six different aspects of human actualization (Ryff 1989): Autonomy, Environmental mastery, Personal growth, Positive relations with others, Purpose in life, and Self-acceptance.
Examining the literature on GCS outcome in the light of the distinction between hedonic and eudaimonic well-being, it can be concluded that research in this field entirely focused on the former while neglecting the latter, as no study has so far analyzed the outcome of GCS in a eudaimonic perspective, nor explored eudaimonic well-being in transsexual people before or after GCS. However, reasons to investigate eudaimonic well-being in transsexual people can be manifold and cogent.
First of all, data on long-term outcome of GCS might be enriched by assuming a eudaimonic perspective which goes beyond satisfaction with hormonal treatment and surgery results on the body, and encompasses more holistic aspects of positive psychological functioning (e.g. whether life is perceived as meaningful and purposeful). In particular, the assessment of eudaimonic well-being may be relevant to individuals belonging to sexual and gender minorities (i.e. gay, lesbian, bisexual, and transgender people) whose identities might involve a long process of self-discovery, exploration, disclosure and “coming out” as part of expressing their authentic self. The studies available on eudaimonic well-being in sexual minorities are very limited in number and focus exclusively on gay and lesbian participants, showing that identifying as lesbian, gay or bisexual is generally associated with lower eudaimonic well-being (Riggle et al. 2009).
A fourteen-stage model of transgender identity formation has been proposed (Devor 2004), based on the model of identity formation originally elaborated by Cass (1979, 1984) for homosexuals. It is important, however, to remark that only for transsexual people (and not for other sexual minorities), surgical and hormonal interventions are necessary in order to foster a full identity development. From this point of view, GCS and cross-sex hormones (CSH) can be viewed as a crucial step in self-realization of a transsexual individual. Although several other models of gender identity formation have been proposed (Lev 2004; Pollock and Eyre 2012; Pinto and Moleiro 2015), they all seem to agree on the crucial role of physical and/or social transition on the transperson’s life. Further evidence from qualitative studies suggests that, in spite of the daunting challenges that transsexual people might face along their path, the transition process is highly rewarding for them, essential in living the life they desire and in assuming an external identity that finally matches who they feel internally (Mullen and Moane 2013).
It might be postulated, therefore, that GCS, in order to be considered a holistically effective medical intervention for GD, should contribute to increase the clients’ eudaimonic well-being.
Another relevant issue that makes eudaimonic well-being worth studying in transsexuals is minority stress and its impact on transsexual people’s lives.
It is now well established that transgender people experience systematic oppression and devaluation connected with social stigma, which was found to be implicated in the high rates of depression, anxiety, somatization, and overall psychological distress in this population (Bockting et al. 2013). Also, transgender people are frequently victims of harassment, verbal and physical violence from both strangers and known people (Harper and Schneider 2003; Prunas et al. 2015), particularly so in Italy that, according to a recent report from Transgender Unite (2013), was the second European country by number of homicides of transgender people between 2008 and 2013.
A report from UK found that the transgender population is, compared to lesbian, gay, and bisexual people, at higher risk of becoming victim of hate crimes: twice as likely to experience physical violence and three times as likely to experience harassment (Browne and Lim 2008). Similar results were also found in a large survey carried out across several European states (Turner et al. 2009). The most recent study has been carried out by the European Union Agency for Fundamental Rights (2014); it involved participants from 28 countries and it showed that more than half of the whole sample of respondents (54 %) felt discriminated against or harassed in the year preceding the survey because they were perceived as trans.
Previous studies have shown that perceived discrimination and its accompanying stress have a negative impact on eudaimonic well-being in people belonging to minorities (in terms of race/ethnicity but also gender and educational status), although such effects were gender-specific (Ryff et al. 2003). No study is available on transsexual and transgender individuals.
To explore and compare eudaimonic well-being in both MtF and FtM transsexuals before and after GCS;
To compare eudaimonic well-being in pre-operative MtF transsexuals who already started therapy with CSH and those who did not, in order to assess the impact on eudaimonic well-being at different stages of the transition process;
To assess the impact of experiences of harassment, discrimination and violence on eudaimonic well-being in post-surgery transsexuals.
Two groups of transsexual clients were sampled for the present study.
2.1.1 Pre-Surgery Sample
Seventy-six participants were consecutively admitted at the Gender Dysphoria Unit at Niguarda Ca’ Granda Hospital (Milan, Italy) between 2011 and December 2014. This is a public hospital located in Northern Italy offering specialized psychiatric, psychological, endocrinological and surgical gender confirming therapy. The center operates according to the International Guidelines proposed by the World Professional Association for Transgender Health (Coleman et al. 2011). Among the participants in this group, 45 were MtF (59 % of the total sample) and 31 were FtM (41 % of the total sample).
Mean age was 32.93 years (SD = ±9.04; range 18–50) in the MtF sample and 31.00 years (SD = ±9.85; range 18–54) in the FtM sample.
In the MtF sample, 74 % of participants had a paid job at time of study participation, 19 % were looking for an occupation, 6 % were full-time students. In the FtM sample, 73 % participants had a paid job, 23 % were looking for an occupation, 4 % were full-time students.
The criteria for inclusion in the study were a formal diagnosis of GD (according to DSM 5; A.P.A. 2013), age above 18 years, and absence of any current major psychiatric disorders (schizophrenia, schizoaffective, schizophreniform or delusional disorder according to DSM-5 criteria, dementia or organic mental disorders, mental retardation and other cognitive disorders, active substance dependence). Inclusion and exclusion criteria were assessed through several sessions with two experienced mental health professionals (i.e. a clinical psychologist and a psychiatrist). All participants requested hormones and surgical treatment for GD. Thirteen participants in the MtF sample (29 %), and none in the FtM sample, were already taking CSH, although not necessarily under medical prescription.
2.1.2 Post-Surgery Sample
Participants in this group were recruited in the context of a larger study aimed at assessing outcome of GCS in Italian transsexuals, whose results are published elsewhere (Prunas et al. 2016). The research was carried out in three different centres providing hormone and/or surgical treatment for people suffering from GD, in line with clinical guidelines provided by the WPATH (Coleman et al. 2011). The centres are located in Milan (Northern Italy), Florence (Central Italy) and Bari (Southern Italy).
Researchers in the three centres contacted by e-mail or telephone all the clients who received GCS in the past in order to ask for participation in the study.
Fifty-nine participants took part to the research, the overall response rate being 30 %.
Among the respondents, 34 were MtF (58 % of the total sample) and 25 were FtM (42 %).
Mean age was 36.09 years (SD = ±8.87) in the MtF sample and 35.32 years (SD = ±7.42) in the FtM sample.
In the MtF sample, 25 (73 %) participants had a paid job at time of study participation, 6 (18 %) were looking for an occupation, 2 (6 %) were full-time students, one (3 %) was a housewife. In the FtM sample, 16 (64 %) participants had a paid job, 8 (32 %) were looking for an occupation, 1 (4 %) were full-time students.
Mean time at assessment after GCS was 4.59 years (SD = ±4.49; range 1–20 years) for MtF and 4.24 years (SD = ±5.46; range 0.5–22 years) for FtM.
As for the participants in the FtM sample, only one underwent phalloplasty; all the others underwent hysteroannessectomy and mastoplasty. All participants in the MtF sample received vaginoplasty and brest surgery.
No difference in mean age was found between the MtF samples before and after surgery (Student’s t = −1.547; df = 77; p > 0.05), nor in the FtM samples (Student’s t = −1.815; df = 54; p > 0.05). No differences were found in occupational status either in MtF (χ2 = 1.554; df = 3; p > 0.05) or FtM (χ2 = 0.308; df = 3; p > 0.05), when comparing the two samples, before and after GCS.
2.2 Materials and Procedure
After providing written informed consent, participants were asked to fill in a questionnaire pack containing an information sheet, a socio-demographic questionnaire and self-report measures, including the Italian version of the 84-item Psychological Well-Being Scales (Ryff 1989; Ruini et al. 2003). In the present study, Cronbach’s alphas for the total sample (N = 135) ranged between 0.785 and 0.890; correlations between subscales ranged between 0.470 (Personalgrowth and Autonomy) and 0.783 (Purpose in life and Environmentalmastery), with a mean value of 0.574.
Participants in the post-surgery sample were also asked to fill in a questionnaire aiming at assessing experiences of discrimination, harassment, violence and crime they might have been victim of after GCS.
The experiences assessed included: being fired or losing a job because of transsexualism; experiencing harassment or discrimination at work from a co-worker, manager or boss, because of transsexualism; experiencing harassment or discrimination from a doctor, nurse, or other health care provider, because of transsexualism; being a victim of violence or crime because of transsexualism.
The questionnaires were completed anonymously, either in a paper-and-pencil format or directly online by means of a survey platform.
The mean scores (i.e. six PWB subscales) of the different groups (pre- and post-surgery) were first compared through a series of univariate ANOVAs (or Student’s t test, as appropriate), and separately for MtFs and FtMs. In case of a significant F test, a contrast analysis (by means of Tuckey post hoc contrasts) was then run for each subscale.
In order to assess the association between experiences of harassment, discrimination and violence, and well-being, we then compared (by means of Student’s t test) the mean scores of the six PWB subscales between participants who reported any of those experiences and those who did not, again separately for MtFs and FtMs.
The study was approved by the IRB of the University of Milano-Bicocca, Milan, Italy.
3.1 Male-to-Female Sample: Pre- and Post-Surgery Comparison
Comparison between MtF transsexuals with no medical therapy, on CSH and after surgery on the six PWB subscales
No medical treatment
(N = 32)
(N = 13)
(N = 34)
F (2, 76)
Purpose in life
In the post-surgery group higher scores on Mastery and Self-Acceptance, and lower scores on PersonalGrowth were found than those in the group who did not receive any medical treatment. Participants who had already started CSH treatment showed higher scores on Self-acceptance compared to their counterparts who had never taken CSH at time of assessment.
In the post-surgery sample, no correlation was found between the number of years since GCS and any of the PWB subscales (all Pearson’s r’s between −0.252 and 0.086; all p’s > 0.05; N = 34).
3.2 Female-to-Male Sample: Pre- and Post-Surgery Comparison
Comparison between FtM transsexuals before and after surgery on the six PWB subscales
(N = 31)
(N = 25)
Purpose in life
Post-surgery transsexuals showed higher scores on Self-Acceptance than the control group before surgery.
No correlation was found between the number of years since GCS and any of the PWB subscales in the post-surgery sample (all Pearson’s r’s between −0.026 and 0.259; all p’s > 0.05; N = 25).
3.3 Experiences of Harassment, Discrimination and Violence, and Well-Being
Experiences of discrimination, harassment and violence in MtF and FtM post-surgery samples
(n = 59)
(n = 34)
(n = 25)
χ2(1)/Fisher exact, p
Ever been fired because of transsexualism
8 (14 %)
7 (20 %)
1 (4 %)
Ever experienced harassment or discrimination at work because of transsexualism
13 (22 %)
10 (29 %)
3 (12 %)
Ever experienced harassment or discrimination from a health care provider because of transsexualism
9 (15 %)
7 (20 %)
2 (8 %)
Ever been a victim of violence or crime because of transsexualism
7 (12 %)
5 (15 %)
2 (8 %)
At least one of the above experiences
22 (37 %)
15 (44 %)
7 (28 %)
Comparison between post-surgery MtF participants who reported experiences of harassment, discrimination and violence and those who did not, on the six PWB subscales
(N = 15)
(N = 19)
Student’s t (32)
Purpose in life
Comparison between post-surgery FtM participants who reported experiences of harassment, discrimination and violence and those who did not, on the six PWB subscales
(N = 7)
(N = 18)
Student’s t (23)
Purpose in life
This is the first study exploring eudaimonic well-being in transsexuals before and after GCS.
Two groups of transsexuals (MtF and FtM) who underwent GCS were compared, using the questionnaire originally elaborated by Ryff (1989), with two samples of transsexual clients who just completed the assessment phase in a public hospital specialized in the treatment of GD. The two samples were matched by age and occupational status, which have been shown to impact considerably on eudaimonic well-being (Ryff 2014).
Our results show that both MtF and FtM scored higher in Self-Acceptance after GCS when compared to participants who did not start any medical treatment. Similarly, in the MtF sample, participants who already started CSH showed higher scores on this subscale than transsexuals with no medical treatment.
According to Ryff (2014, p. 12), high scores on Self-Acceptance are indicative of a person who “possesses a positive attitude toward the self; acknowledges and accepts multiple aspects of self, including good and bad qualities; feels positive about past life”.
Acceptance of post-transition gender identity has been postulated as a specific stage in the transsexual identity formation model (Devor 2004). This step implies that, once transition is completed, individuals have to experience more deeply the implications of being a person of the gender to which they transitioned. Accumulating experiences in everyday life allows them to develop a true and authentic sense of themselves as members of their reassigned gender. Furthermore, being routinely and consistently witnessed and mirrored as who they felt to be contributes to reducing previous anxiety and fears which are progressively replaced by a more serene self-acceptance (Devor 2004). Our results seem to support this model.
In the MtF sample a significantly higher score on Environmental Mastery and a lower score on Personal Growth were found when compared to the sample with no medical treatments.
High scores in Environmental Mastery indicate an individual who “has a sense of mastery and competence in managing the environment, who controls complex array of external activities, makes effective use of surrounding opportunities and is able to choose or create contexts suitable to personal needs and values” (Ryff 2014, p. 12).
As for the lower scores on Personal Growth we hypothesize that having achieved such an important and highly invested upon goal (i.e. GCS) might result in the perception of low further potential for change and growth in the future. High scores on this scale are in fact indicative of an individual who “has a feeling of continued development, sees self as growing and expanding, is open to new experiences, has sense of realizing his or her potential; sees improvement in self and behavior over time; is changing in ways that reflect more self-knowledge and effectiveness” (Ryff 2014, p. 12).
By comparing MtF transsexuals at different stages of the transition process, our results show that the changes in Self-acceptance seem to occur when the medical interventions are undergone (i.e. CSH) and remain stable after GCS; this result is also supported by the fact that no correlation was found between the number of years since GCS and eudaimonic well-being, on any of the PWB subscales.
We also studied the association between experiences of harassment, discrimination and violence, and eudaimonic well-being in transsexual participants who have undergone GCS. Although the prevalence of such experiences is not different between the two groups, our results show that, only in the FtM sample, participants who reported any of such experiences have higher scores on Personal growth than those who did not.
The results for both the MtF and the FtM sample are at odds with previous studies showing that being discriminated against significantly reduces eudaimonic well-being (Ryff et al. 2003). As for trans men, it can be hypothesized that, at least for some individuals, experiences of stigmatization or discrimination may provide opportunities to build effective coping skills and resources that may boost eudaimonic well-being. Also, having to face the challenges of disclosing a stigmatized sexual identity, for some individuals belonging to sexual minorities, might promote the achievement of eudaimonic well-being (Riggle et al. 2008). This might be particularly true as, in the present study, only experiences of discrimination occurred after GCS were considered. It might be hypothesized that, once transition is completed and higher levels of eudaimonic well-being are achieved, experiences of discrimination might have a lower impact on the trans person, than it is the case before the transition. Further studies are necessary to support this hypothesis. As for trans women, on the contrary, the finding of no impact of experiences of discrimination and violence on well-being may be explained as a result of the surgery, and the legal recognition of the desired gender that follows. It must be reminded that in Italy the change in civil status through the courts is currently possible only after genital surgery. The official recognition of one’s own experienced gender might be an important factor that buffers the effects of the negative experiences of discrimination and violence that, in this particular sample, are reported to be frequent. Again, considering the lack of previous studies on the topic, more research is needed to support the results of the current study.
The present study suffers from several methodological limitations.
First of all, future studies should provide further evidence of the impact of GCS by following up the same group of clients and assessing their levels of well-being before and after surgery, and at different stages of the medical transition process. Such a study design might help understand whether some dimensions of well-being are not actually the direct result of the transition process but rather a pre-condition to it. For instance, high scores on Environmental Mastery may make individuals feel more competent in managing the environment and making effective use of available resources, thus creating a more suitable context to their personal needs and values. Individuals with such characteristics might be less at risk of drop-out when they start the assessment process for GD, and might benefit more from all possible interventions that are offered to them.
Second, the sample under investigation cannot be considered representative for all transsexual clients, but rather for transsexual clients requesting GCS according to the International Standards of Care. This is not at all a complete picture of the trans population which is characterized by high levels of heterogeneity (Giami and Beaubatie 2014). For instance, all the participants in the present study requested a full transition (i.e. hormonal treatment and genital surgery), so results cannot be generalized to transgender people who only request partial treatments (i.e. only hormonal treatment or breast surgery).
Third, although the rate of returned questionnaires in the post-surgery sample (i.e. 30 %) is comparable with previous outcome studies of the same kind (Lawrence 2003), it is plausible that the study participants may not constitute a representative sample of all those who underwent GCS at the three centers, nor of the overall population of Italian transsexuals who ever underwent GCS. No reliable data have ever been provided on the exact number of GCSs carried out in the Country and estimates currently available are in fact tentative and marked by some relevant methodological drawbacks (Caldarera and Pfäfflin 2011).
Finally, non-respondents among those who had already received GCS were not contacted to assess the presence of relevant differences from respondents. Persons who experienced positive results might have been more likely to reply and take part in the current research because of their feelings of gratitude towards the clinicians; on the contrary, some individuals who experienced unsatisfactory surgical outcomes might have committed suicide, become isolated or been victim of transphobic violence (Dhejne et al. 2011; Prunas et al. 2015); these factors might have biased our results toward more positive outcomes. It must be pointed out that all the post-surgery participants in the survey were highly satisfied with the surgery outcome and none of them ever experienced regret after GCS.
In spite of these drawbacks, our study shows that transsexual people who receive hormonal and surgical treatments for GD show higher levels of eudaimonic well-being than controls who just started the assessment process in a specialized facility. Also, although experiences of harassment, discrimination and violence are alarmingly high in this population, they seem to have a limited impact on psychological well-being after GCS and might possibly become an opportunity for personal growth.
The term “transgender” is often used as an umbrella term to designate people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. Within this category, transsexual people are those whose gender identity is the opposite of the assigned sex at birth, and therefore pursue hormonal and/or surgical treatments. Transsexual women are often referred to as Male-to-Female (MtF), while transsexual men as Female-to-Male (FtM). Although some authors and some trans people still adopt the term transgender even when explicitly referring to transsexual people, in Italy the term transsexual is still widely used and all the participants in the present study self-identified as such.
The authors are heartily grateful to Patrizia Steca, PhD, and Dario Monzani, PhD, for precious comments on a previous draft of this paper.
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