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Challenges in assessing personality of individuals with Gender Dysphoria with the SWAP-200

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Abstract

Background

Personality assessment can be useful to better understand the complexity of transgender and transsexual people. In particular, the Shedler Westen Assessment Procedure-200 (SWAP-200) is a measure that provides an accurate dimensional evaluation of personality. When assessing gender non-conforming people, however, clinicians can encounter some difficulties in giving appropriate ratings to all the items.

Purpose of the review

A brief guide to the use of SWAP-200 with transgender patients is provided, taking into account three areas of psychological functioning: identity, relationships and sexuality. The authors review, one by one, the SWAP-200 items related to these areas, and, relying on their clinical experience and on scientific literature on Gender Dysphoria, they propose recommendations for making personality diagnoses meaningful.

Conclusion

This paper facilitates a better clinical understanding of transgender people, and help clinicians to be more knowledgeable in the assessment of this heterogeneous population.

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Notes

  1. SAIFIP stands for the Italian “Servizio per l’Adeguamento dell’Identità Fisica all’Identità Psichica” (Service for the Adaptation between Physical Identity and Psychical Identity), a gender clinic at the San Camillo-Forlanini Hospital of Rome. The SAIFIP team offers many therapeutic procedures (hormone therapy, surgery, counselling, and psychotherapy) and follows international standards of care for treatment of people with Gender Dysphoria [25].

  2. With regard to pronouns, in our paper we chose to opt for feminine forms for Maria (name assigned at birth: Mario), and for masculine terms for Giulio (name assigned at birth: Giulia), reflecting their experienced and chosen gender. In addition, we did not use forms widely used like “male-to-female” (MtF) or “female-to-male” (FtM), following Serano [39] suggestions to use a less discriminatory terminology. To this respect, we also wish to thank MD Jack Drescher (member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders and of the ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health) for his advice and information..

  3. SWAP-200 case formulations usually are individualized (ideographic) personality portraits made by the list of the statements that receive the highest rankings in patients’ SWAP–200 descriptions (items with scores of 5, 6, and 7). Here, for the sake of brevity, we provide a shorter formulation using only the items with score 7 and some of the items with score 6..

  4. “Noncomplementary relationships” means that the majority of female partners of trans women have an androphilic (eterosexual) sexual orientation, corresponding to their male sex assigned at birth, but not complementary to their identified female gender.

References

  1. Drescher JD, Cohen-Kettenis PT, Reed GM (2016) Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale. Lancet. Psychiatry 3:297–304

    PubMed  Google Scholar 

  2. Erickson-Schroth L (2013) Update on the biology of transgender identity. J Gay Lesbian Mental Health 17:150–174

    Article  Google Scholar 

  3. Erickson-Schroth L (2014) Trans bodies, trans selves: A resource for the transgender community. Oxford University Press, New York

    Google Scholar 

  4. Stryker S (2008) Transgender history. Seal Press, Berkeley, CA

    Google Scholar 

  5. Olson-Kennedy J, Cohen-Kettenis PT, Kreukels BPC, Meyer-Bahlburg HFL, Garofalo R, Meyer W et al. (2016) Research priorities for gender nonconforming/transgender youth: gender identity development and biopsychosocial outcomes. Curr Opin Endocrinol Diabetes Obes 23:1–8

  6. Ristori J, Steensma TD (2016) Gender dysphoria in childhood. Int Rev Psychiatry 28:13–20. doi:10.3109/09540261.2015.1115754

    Article  PubMed  Google Scholar 

  7. Schneider C, Cerwenka S, Nieder TO, Briken P, Cohen-Kettenis PT, De Cuypere G et al (2016) Measuring gender dysphoria: a multicenter examination and comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Arch Sex Behav 45:551–558

    Article  PubMed  Google Scholar 

  8. American Psychological Association (2015) Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol 70:832–864. doi:10.1037/a0039906

    Article  Google Scholar 

  9. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J et al (2011) Standards of care for the health of transsexual, transgender, and gender-non- conforming people, version 7. Int J Transgend 13:165–232

  10. World Professional Association for Transgender Health (2011) Standards of care for the health of transsexual, transgender and gender non-conforming people, 7th version

  11. 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

    Article  CAS  PubMed  Google Scholar 

  12. Fisher AD, Castellini G, Bandini E, Casale H, Fanni E, Benni L, … Rellini, AH (2014) Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria. J Sex Med 11:709–719

    Article  CAS  PubMed  Google Scholar 

  13. Fisher AD, Castellini G, Ristori J, Casale H, Cassioli E, Sensi C, Fanni E, Amato ML, Bettini E, Mosconi M, Dèttore D, Ricca V, Maggi M (2016) Cross-sex hormone treatment and psychobiological changes in transsexual persons: 2-yr follow-up data. J Clin Endocrinol Metabol 101:4260–4269

    Article  CAS  Google Scholar 

  14. Newfield E, Hart S, Dibble S, Kohler L (2006) Female-to-male transgender quality of life. Qual Life Res 15:1447–1457. doi:10.1007/s11136-006-0002-3

    Article  PubMed  Google Scholar 

  15. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, Molero F, Montejo AL (2015) Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med 12:180–188. doi:10.1111/jsm.12758

    Article  PubMed  Google Scholar 

  16. Fabris B, Bernardi S, Trombetta C (2015) Cross-sex hormone therapy for gender dysphoria. J Endocrinol Invest 38:269–282

    Article  CAS  PubMed  Google Scholar 

  17. Meriggiola MC, Berra M (2013) Safety of hormonal treatment in transgenders. Curr Opin Endocrinol Diabetes Obes 20:565–569

    Article  CAS  PubMed  Google Scholar 

  18. Cohen-Kettenis PT, van Goozen SHM (1997) Sex reassignment of adolescent transsexuals: a follow-up study. J Am Acad Child Adolesc Psychiatry 36:263–271. doi:10.1097/00004583-199702000-00017

    Article  CAS  PubMed  Google Scholar 

  19. Deogracias JJ, Johnson LL, Meyer-Bahlburg HF, Kessler SJ, Schober JM, Zucker KJ (2007) The gender identity/gender dysphoria questionnaire for adolescents and adults. J Sex Res 44:370–379

    Article  PubMed  Google Scholar 

  20. Westen D, Shedler J (1999) Revising and assessing Axis II, Part I: developing a clinically and empirically valid assessment method. Am J Psychiatry 156:258–272

    CAS  PubMed  Google Scholar 

  21. Westen D, Shedler J (1999) Revising and assessing Axis II, Part II: toward an empirically based and clinically useful classification of personality disorders. Am J Psychiatry 156:273–285

    CAS  PubMed  Google Scholar 

  22. Gazzillo F, Lingiardi V, Peloso A, Giordani S, Vesco S et al (2013) Personality subtypes in adolescents with anorexia nervosa. Compr Psychiatry 54:702–712

    Article  PubMed  Google Scholar 

  23. Russ E, Bradley R, Shedler J, Westen D (2008) Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry 165:1473–1481

    Article  PubMed  Google Scholar 

  24. Lingiardi V, Giovanardi G, Fortunato A, Nassisi V, Speranza AM (in press) Personality and attachment in transsexual adults. Arch Sex Behav. doi:10.1007/s10508-017-0946-0

  25. Chianura L, Palleschi L, Felici N (2014) The twenty years long experience of the “San Camillo—Forlanini” Public Hospital Corporation SAIFIP (Centre for the treatment of Gender Identity Disorders and Sex Reassignment Therapy) in Rome. Salute e Società 2EN:109–126

  26. Westen D, Shedler J, Bradley B, Defife JA (2012) An empirically derived taxonomy for personality diagnosis: Bridging science and practice in conceptualizing personality. Am J Psychiatry 169:273–284

    Article  PubMed  PubMed Central  Google Scholar 

  27. Diener MJ, Hilsenroth MJ (2004) Multimethod validity assessment of the SWAP-200 dysphoric Q-factor. J Nerv Ment Dis 192:479–486

    Article  PubMed  Google Scholar 

  28. Shedler J, Westen D (2004) Dimensions of personality pathology: an alternative to the Five-Factor Model. Am J Psychiatry 161:1743–1754

    Article  PubMed  Google Scholar 

  29. Smith SW, Hilsenroth MJ, Bornstein RF (2009) Convergent validity of the SWAP-200 dependency scales. J Nerv Ment Dis 197:613–618

    Article  PubMed  Google Scholar 

  30. Westen D, Muderrisoglu S (2003) Reliability and validity of personality disorder assessment using a systematic clinical interview. Unpublished manuscript. Emory University, Atlanta, GA

    Google Scholar 

  31. Westen D, Shedler J (2000) A prototype matching approach to personality disorders: Toward DSM–V. J Personal Disord 14:109–126

    Article  CAS  Google Scholar 

  32. Lingiardi V, Gazzillo F, Waldron S (2010) An empirically supported psychoanalysis. The case of Giovanna. Psychoanal Psychol 27:190–218

  33. Lingiardi V, Shedler J, Gazzillo F (2006) Assessing personality change in psychotherapy with the SWAP–200. A case Study. J Pers Assess 86:23–32

    Article  PubMed  Google Scholar 

  34. Waldron S, Moscovitz S, Lundin J, Helm FL, Jemerin J, Gorman B (2011) Evaluating the outcomes of psychotherapies: the Personality Health Index. Psychoanal Psychol 28:363–388

  35. Marin-Avellan LE, McGauley G, Campbell C, Fonagy P (2005) Using the SWAP–200 in a personality-disordered forensic population: is it valid, reliable and useful? J Crim Behav Mental Health 15:28–45

    Article  Google Scholar 

  36. Shedler J, Westen D (1998) Refining the measurement of Axis II: a Q-sort procedure for assessing personality pathology. Assessment 5:333–353

    Article  CAS  PubMed  Google Scholar 

  37. Westen D, Shedler J, Durrett C, Glass S, Martens A (2003) Personality diagnoses in adolescence: DSM–IV Axis II diagnoses and an empirically derived alternative. Am J Psychiatry 160:952–966

    Article  PubMed  Google Scholar 

  38. Westen D, Weinberger J (2004) When clinical description becomes statistical prediction. Am Psychol 59:595–613

    Article  PubMed  Google Scholar 

  39. Serano J (2007) Whipping girl: a transsexual woman on sexism and the scapegoating of femininity. Seal Press, Emeryville, CA

    Google Scholar 

  40. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Author, Washington DC

  41. Di Ceglie D (1998) A stranger in my own body: Atypical gender identity development and mental health. Karnac Books, London

    Google Scholar 

  42. Chiland C (2003) Le transsexualisme. PUF, Paris

    Google Scholar 

  43. Stoller RJ (1968) Sex and genderm, vol 1. Science House, New York

  44. Coates SW, Moore MS (1997) The complexity of early trauma: representation and transformation. Psychoanal Inq 17:286–311

  45. Drescher JD, Byne W (2013) Introduction: the treatment of gender dysphoric/gender variant children and adolescents. In: Drescher J, Byne W (eds) Treating transgender children and adolescents: an interdisciplinary discussion. Routledge, New York

    Google Scholar 

  46. Beatrice J (1985) A psychological comparison of heterosexuals, transvestites, preoperative transsexuals and postoperative transsexuals. J Nerv Ment Dis 173:355–365

    Article  Google Scholar 

  47. Bodlund O, Armelius K (1994) Self-image and personality traits in gender identity disorders: an empirical study. Journal of Sex Marital Therapy 20:303–317. doi:10.1080/00926239408404380

    Article  CAS  PubMed  Google Scholar 

  48. Wolfradt U, Neumann K (2001) Depersonalization, self-esteem and body image in male-to-female transsexuals compared to male and female controls. Arch Sex Behav 30:301–310

    Article  CAS  PubMed  Google Scholar 

  49. Jones BA, Haycraft E, Murjan S, Arcelus J (2016) Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. Int Rev Psychiatry 28:81–94. doi:10.3109/09540261.2015.1089217

    Article  PubMed  Google Scholar 

  50. Ålgars M, Alanko K, Santtila P, Sandnabba NK (2012) Disordered eating and gender identity disorder: a qualitative study. Eat Disord 20:300–311. doi:10.1080/10640266.2012.668482

    Article  PubMed  Google Scholar 

  51. Kozee HB, Tylka TL, Bauerband LA (2012) Measuring transgender individuals’ comfort with gender identity and appearance: Development and validation of the Transgender Congruence Scale. Psychol Women Q 36:179–196

  52. Vocks S, Stahn C, Loenser K, Legenbauer T (2009) Eating and body image disturbances in male-to-female and female-to-male transsexuals. Arch Sex Behav 38:364–377

    Article  PubMed  Google Scholar 

  53. de Vries ALC, McGuire JK, Steensma TD, Wagenaar ECF, Doreleijers TAH, Cohen-Kettenis PT (2014) Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 134:1–9

    Article  Google Scholar 

  54. Kraemer B, Delsignore A, Schnyder U, Hepp U (2008) Body image and transsexualism. Psychopathology 41:96–100

    Article  PubMed  Google Scholar 

  55. Van de Grift TC, Cohen-Kettenis PT, Steensma TD, De Cuypere G, Richter-Appelt H, Haraldsen IR et al (2016) Body satisfaction and physical appearance in gender dysphoria. Arch Sex Behav 45:575–585

    Article  PubMed  Google Scholar 

  56. Case KA, Stewart B (2013) Intervention effectiveness in reducing prejudice against transsexuals. J LGBT Youth 10:140–158

    Article  Google Scholar 

  57. Clements-Nolle K, Marx R, Katz M (2006) Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex 51:53–69

    Article  PubMed  Google Scholar 

  58. Davey A, Bouman WP, Arcelus J, Meyer C (2014) Social support and psychological well-being: a comparison of patients with gender dysphoria and matched controls. J Sex Med. doi:10.1111/jsm.12681

    PubMed  Google Scholar 

  59. Holt V, Skagerberg E, Dunsford M (2016) Young people with features of gender dysphoria: demographics and associated difficulties. Clin Child Psychol Psychiatry 21:108–118

    Article  PubMed  Google Scholar 

  60. Shiffman M, VanderLaan DP, Wood H, Hughes SK, Owen-Anderson A, Lumley MM et al (2016) Behavioral and emotional problems as a function of peer relationships in adolescents With Gender Dysphoria: a comparison with clinical and nonclinical controls. Psychol Sexual Orient Gender Diversity 3:27–36

  61. Marshall E, Claes L, Bouman WP, Witcomb GL, Arcelus J (2016) Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature. Int Rev Psychiatry 28:58–69. doi:10.3109/09540261.2015.1073143

    Article  PubMed  Google Scholar 

  62. Blanchard R (1989) The concept of autogynephilia and the typology of male gender dysphoria. J Nerv Ment Dis 177:616–623

    Article  CAS  PubMed  Google Scholar 

  63. Lawrence AA (2010) Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults. Arch Sex Behav 39:514–545

    Article  PubMed  Google Scholar 

  64. Cohen-Kettenis PT, Pfäfflin F (2010) The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Arch Sex Behav 39:499–513

    Article  PubMed  Google Scholar 

  65. Nieder TO, Elaut E, Richards C, Dekker A (2016) Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking. Int Rev Psychiatry 28:103–111. doi:10.3109/09540261.2015.1102127

    Article  PubMed  Google Scholar 

  66. Smith Y, Van Goozen SHM, Kuiper AJ, Cohen-Kettenis PT (2005) Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med 35:89–99

    Article  PubMed  Google Scholar 

  67. Smith Y, Van Goozen SHM, Kuiper AJ, Cohen-Kettenis PT (2005) Transsexual subtypes: clinical and theoretical significance. Psychiatry Res 137:151–160

    Article  PubMed  Google Scholar 

  68. Cohen-Kettenis PT, Elaut E, Kreukels BPC (2015) Psychological characteristics and sexuality of natal males with Gender Dysphoria. In: Trombetta C, Liguori G, Bertolotto M (eds) Management of Gender Dysphoria: a multidisciplinary approach. Springer Verlag, New York, Milano

    Google Scholar 

  69. Zucker K, Cohen-Kettenis P, Drescher J, Meyer-Bahlburg HL, Pfäfflin F, Womack W (2013) Memo outlining evidence for change for gender identity disorder in the DSM-5. Arch Sex Behav 42:901–914

    Article  PubMed  Google Scholar 

  70. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, Arlington, VA

    Book  Google Scholar 

  71. Drescher JD, Cohen-Kettenis PT, Winter S (2012) Minding the body: Situating gender identity diagnoses in the ICD-11. Int Rev Psychiatry 24:568–577

    Article  PubMed  Google Scholar 

  72. Lingiardi V (2015) No maps for uncharted lands. What does gender expression have to do with sexual orientation? In: Lemma A, Lynch P (eds) Sexualities: contemporary psychoanalytic perspectives. Routledge, London

    Google Scholar 

  73. Money J, Gaskin R (1970–1971) Sex reassignment. Int J Psychiat 9:249–269

  74. Person E, Ovesey L (1974) The transsexual syndrome in males: I. Primary transsexualism. Am J Psychother 28:4–20

    CAS  PubMed  Google Scholar 

  75. Cerwenka S, Nieder TO, Cohen-Kettenis PT, De Cuypere G, Haraldsen IRH, Kreukels BPC et al (2014) Sexual behavior of gender dysphoric individuals before gender-confirming interventions: a European multi-center perspective. J Sex Marital Ther. doi:10.1080/0092623X.2013.772550

    PubMed  Google Scholar 

  76. Lawrence AA (2005) Sexuality before and after male-to-female sex reassignment surgery. Arch Sex Behav 34:147–166

    Article  PubMed  Google Scholar 

  77. Klein C, Gorzalka BB (2009) Sexual functioning in transsexuals following hormone therapy and genital surgery: a review. J Sex Med 1370:2922–2940

    Article  Google Scholar 

  78. Cerwenka S, Nieder TO, Briken P, Cohen-Kettenis PT, De Cuypere G, Haraldsen IRH et al (2014) Intimate partnerships and sexual health in gender dysphoric individuals before the start of medical treatments. Int J Sex Health 26:52–65

    Article  Google Scholar 

  79. Greenacre P (1969) The fetish and the transitional object. Psychoanal Study Child 24:144–164

    CAS  PubMed  Google Scholar 

  80. Greenson RR (1968) Dis-identifying from mother. Int J Psychoanal 49:370–374

    CAS  PubMed  Google Scholar 

  81. Chou D, Cottler S, Khosla R, Reed GM, Say L (2015) Sexual health in the International Classification of Diseases (ICD): implications for measurement and beyond. Reprod Health Matter 23:185–92

  82. Robles R, Fresán A, Vega-Ramírez H, Cruz-Islas J, Rodríguez-Pérez V, Domínguez-Martínez T et al (2016) Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry. doi:10.1016/S2215-0366(16)30165-1

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  1. Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi 78, 00185, Rome, Italy

    V. Lingiardi & G. Giovanardi

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  1. V. Lingiardi
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Correspondence to V. Lingiardi.

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Lingiardi, V., Giovanardi, G. Challenges in assessing personality of individuals with Gender Dysphoria with the SWAP-200. J Endocrinol Invest 40, 693–703 (2017). https://doi.org/10.1007/s40618-017-0629-7

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