Psychiatric Comorbidity in Adults with Gender Identity Problems

  • Luk Gijs
  • Ellis van der Putten-Bierman
  • Griet De Cuypere
Part of the Focus on Sexuality Research book series (FOSR)

Abstract

For many decades of the twentieth century, gender dysphoria was seen as an intrinsic symptom of another psychiatric disorder (e.g., schizophrenia) that should be resolved by addressing the “underlying” psychiatric disorder. DSM-III (American Psychiatric Association, 1980) broke with that view and classified the gender identity disorders as a separate category of psychopathology. In contrast, many argue today that gender nonconformity and even gender dysphoria are not (psycho)pathology per se and that sex reassignment therapies are the most effective therapies for gender dysphoria (e.g., World Professional Association for Transgender Health, 2011).

However, based on the prevalence rate of comorbidity, many are convinced that the diagnosis and treatment of psychiatric comorbidity is of paramount importance for a proper diagnosis and for a successful treatment of gender dysphoria.

This chapter reviews the prevalence rate of comorbid Axis I and II disorders in persons with gender dysphoria (GD), explores theoretical models to explain comorbidity, and describes clinical implications. The central message is that we should avoid two pitfalls: First, we should avoid the assumption that all patients with GD must have comorbid disorders, and second, we should not assume that patients with GD will not have comorbid disorders. However, to ensure the best possible outcome of sex reassignment therapy and to prevent regret, comorbidity should be diagnosed and treated properly.

Keywords

Depression Estrogen Schizophrenia Androgen Milo 

References

  1. á Campo, J., Nijman, H., Merckelbach, H., & Evers, C. (2003). Psychiatric comorbidity of gender identity disorders: A survey among Dutch psychiatrists. The American Journal of Psychiatry, 160, 1332–1336.PubMedCrossRefGoogle Scholar
  2. Algars, M., Alanko, K., Santttila, P., & Sandnabba, N. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders, 20, 300–311.PubMedCrossRefGoogle Scholar
  3. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association.Google Scholar
  4. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. - Text Revision). Washington, DC: American Psychiatric Association.Google Scholar
  5. Andrade, A., Kumaraiah, V., Mishra, H., Chatterji, S., & Andrade, C. (1995). Behaviour therapy for transsexualism. Indian Journal of Psychiatry, 37(3), 148–150.PubMedGoogle Scholar
  6. Baltieri, D., & De Andrade, A. (2009). Schizophrenia modifying the expression of gender identity disorder. The Journal of Sexual Medicine, 6, 1185–1188.PubMedCrossRefGoogle Scholar
  7. Barlow, D., & Abel, G. (1976). Sexual deviation. In W. Craighead, A. Kazdin, & M. Mahoney (Eds.), Behavior modification: Principles, issues, and applications (pp. 341–360). Boston: Houghton Mifflin.Google Scholar
  8. Barlow, D., Abel, G., & Blanchard, E. (1979). Gender identity change in transsexuals. Follow-up and replications. Archives of General Psychiatry, 36, 1001–1007.CrossRefGoogle Scholar
  9. Barlow, D., Reynolds, E., & Agras, W. (1973). Gender identity change in a transsexual. Archives of General Psychiatry, 28, 569–576.PubMedCrossRefGoogle Scholar
  10. Bockting, W. (2008). Psychotherapy and the real-life experience: from gender dichotomy to gender diversity. Sexologies, 17, 211–224.CrossRefGoogle Scholar
  11. Bockting, W., Coleman, E., & Benner, A., (2007). Stigma, mental health, and resilience among the U.S. Transgender population. 1st World Congress for sexual health. Cited in Bockting (2008).Google Scholar
  12. Borras, L., Huguelet, P., & Eytan, A. (2007). Delusional ´´pseudotranssexualism´´ in schizophrenia. Psychiatry, 70, 175–179.PubMedGoogle Scholar
  13. Brownell, K., & Barlow, D. (1980). The behavioral treatment of sexual deviation. In A. Goldstein & E. Foa (Eds.), Handbook of behavioral interventions: A clinical guide (pp. 604–672). New York: Wiley.Google Scholar
  14. Byne, W., Bradley, S., Coleman, E., Eyler, A., Green, R., Menvielle, E., et al. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behaviour, 41, 759–896.CrossRefGoogle Scholar
  15. Chiland, C. (2003). Transsexualism; Illusions and reality. London: Continuum.Google Scholar
  16. Cochran, S., & Mays, V. (2006). Estimating prevalence of mental and substance-suing disorders among lesbians and gay men from existing national health data. In A. Omoto & H. Kurtzman (Eds.), Sexual orientation and mental health (pp. 143–1650). Washington: American Psychological Association.Google Scholar
  17. Cole, C., O’Boyle, M., Emory, L., & Meyer, W. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26, 13–26.PubMedCrossRefGoogle Scholar
  18. Cramer, A., Waldorp, L., Han, L., Van der Maas, J., & Borsboom, D. (2010). Comorbidity: A network perspective. Behavioural and Brain Sciences, 33, 137–150.CrossRefGoogle Scholar
  19. De Cuypere, G. (1993). Schizophrenia and symptomatic transsexualism: Two case reports. European Psychiatry, 8, 163–167.Google Scholar
  20. De Vries, A., Noens, I., Cohen-Kettenis, P., van Berckelaer-Onnes, I., & Doreleijers, T. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40, 930–936.PubMedCrossRefGoogle Scholar
  21. Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A., Langstrom, N., & Landen, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study Sweden. PLoS One, 22, e16885. doi: 10.1371.CrossRefGoogle Scholar
  22. Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender identity dysphoria in adults and adolescents: Recent developments, effectiveness, and change. Annual Review of Sex Research, 18, 178–224.Google Scholar
  23. Gómez-Gil, E., Vidal-Hagemeijer, A., & Salamero, M. (2008). MMPI-2 characteristics of transsexuals requesting sex reassignment: Comparison of patients in prehormonal and presurgical phases. Journal of Personality Assessment, 90, 368–374.PubMedCrossRefGoogle Scholar
  24. Haas, A., Eliason, M., Mays, V., Mathy, R., Cochran, S., D’Augelli, A., et al. (2011). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58, 10–51.PubMedCrossRefGoogle Scholar
  25. Haraldsen, I., & Dahl, A. (2000). Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorder and healthy adults. Acta Psychiatrica Scandinavia, 102, 276–281.CrossRefGoogle Scholar
  26. Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, A. (2005). Psychiatric comorbidity in gender identity disorder. Journal of Psychosomatic Research, 58, 259–261.PubMedCrossRefGoogle Scholar
  27. Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32, 473–478.PubMedCrossRefGoogle Scholar
  28. Heylens, G., Elaut, E., Kreukels, B., Paap, M., Cerwenka, S., Richter-Appelt, H., et al. (2013). Psychiatric characteristics in transsexual individuals: A multi-centre study in four European countries. The British Journal of Psychiatry 202. DOI: 10.1192/bjp.bp.112.121954.Google Scholar
  29. Hines, M. (2011). Gender development and the human brain. Annual Review of Neuroscience, 34, 69–88.PubMedCrossRefGoogle Scholar
  30. Hoenig, J., & Kenna, J. (1974). The prevalence of transsexualism in England and Wales. Britisch Journal of Psychiatry, 124, 181–190.CrossRefGoogle Scholar
  31. Hyman, S. (2010). The diagnosis of mental disorders: The problem of reification. Annual Review of Clinical Psychology, 6, 155–179.PubMedCrossRefGoogle Scholar
  32. Jones, R., Wheelwright, S., Farrell, K., Martin, E., Green, R., Di Ceglie, D., et al. (2012). Brief report: Female-to-male transsexual people and autistic traits. Journal of Autism and Developmental Disorders, 42, 301–306.PubMedCrossRefGoogle Scholar
  33. Kuhn, A., Bodmer, C., Stadlmayer, W., Kuhn, P., Mueller, M., & Birkhauser, M. (2009). Quality of life 15 years after sex reassignment surgery for transsexualism. Fertility and Sterility, 92, 1685–1689.PubMedCrossRefGoogle Scholar
  34. Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior, 32, 229–315.Google Scholar
  35. Lawrence, A. (2007). Transgender health concerns. In I. Meyer & M. Northbridge (Eds.), The health of sexual minorities. Public health perspectives on lesbian, gay, bisexual and transgender populations (pp. 473–505). New York, NY: Springer.CrossRefGoogle Scholar
  36. Lawrence, A., & Zucker, K. (2012). Gender identity disorders. In M. Hersen & D. Beidel (Eds.), Adult psychopathology and diagnosis (6th ed., pp. 601–635). London: Wiley.Google Scholar
  37. Lehavot, K., & Simoni, J. (2011). The impact of minority stress on mental health and substance abuse among sexual minority women. Journal of Consulting and Clinical Psychology, 79, 159–170.PubMedCrossRefGoogle Scholar
  38. Lev, A. (2004). Transgender emergence. Therapeutic guidelines for working with gender-variant people and their families. London: Routledge.Google Scholar
  39. Levine, S., & Solomon, A. (2010). Meanings and political implications of “Psychopathology” in a gender identity clinic: A report of 10 cases. Journal of Sex & Marital Therapy, 35, 40–57.CrossRefGoogle Scholar
  40. Links, P., Ansari, J., Fazalullasha, F., & Shah, R. (2012). The relationship of personality disorders and Axis I clinical disorders. In T. Widiger (Ed.), The Oxford handbook of personality disorders (pp. 237–259). Oxford: Oxford University Press.Google Scholar
  41. Madeddu, F., Prunas, A., & Hartmann, D. (2009). Prevalence of Axis II disorders in a sample of clients undertaking psychiatric evaluation for sex reassignment surgery. Psychiatric Quarterly, 80, 261–267.PubMedCrossRefGoogle Scholar
  42. Marks, I., Green, R., & Mataix-Cole, D. (2000). Adult gender identity disorder can remit. Comprehensive Psychiatry, 41, 273–275.PubMedCrossRefGoogle Scholar
  43. Marks, I., & Mataix-Cole, D. (1997). Four-year remission of transsexualism after comorbid obsessive-compulsive disorder improved with self-exposure therapy. The British Journal of Psychiatry, 171, 389–390.PubMedCrossRefGoogle Scholar
  44. McLaughlin, K., Hatzenbuehler, M., Xuan, Z., & Conron, K. (2012). Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric co-morbidity. Child Abuse & Neglect, 36, 645–655.CrossRefGoogle Scholar
  45. Meijer, I. (2007). Prejudice and discrimination as social stressors. In I. Meyer & M. Northhridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual and transgender populations (pp. 222–267). New York: Springer.Google Scholar
  46. Meyerowitz, J. (2002). How sex changed. A history of transsexuality in the United States. Cambridge: Harvard University Press.Google Scholar
  47. Mizock, L., & Fleming, M. (2011). Transgender and gender variant populations with mental illness: Implications for clinical care. Professional Psychology: Research and Practice, 42, 208–213.CrossRefGoogle Scholar
  48. Murad, M., Elamin, M., Garcia, M., Mullan, R., Murad, A., Erwin, P., et al. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72, 214–231.PubMedCrossRefGoogle Scholar
  49. Neeleman, A. (2007). The relevance of sexuality in the treatment of borderline personality disorder. Tijdschrift voor Psychiatrie, 49, 233–240.PubMedGoogle Scholar
  50. Newcomb, M., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review, 8, 1019–1029.CrossRefGoogle Scholar
  51. Nuttbrock, L., Hwanhng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., et al. (2009). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 46, 1–12.CrossRefGoogle Scholar
  52. Parks, G., & Hall, I. (2006). Gender dysphoria and cross-dressing in people with intellectual disability: A literature review. Mental Retardation, 44, 260–271.CrossRefGoogle Scholar
  53. Pfäfflin, F. (1992). Regrets after sex reassignment surgery. Journal of Psychology and Human Sexuality, 5, 69–85.CrossRefGoogle Scholar
  54. Selvaggi, G., & Bellringer, J. (2011). Gender reassignment surgery: An overview. Nature Reviews Urology, 8, 274–282.PubMedCrossRefGoogle Scholar
  55. Singh, A. (in press). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles.Google Scholar
  56. Singh, D., McMain, S., & Zucker, K. (2011). Gender identity and sexual orientation in woman with borderline personality disorder. The Journal of Sexual Medicine, 8, 447–454.PubMedCrossRefGoogle Scholar
  57. Slatman, J., & Widdershoven, G. (2009). Being whole after amputation. The American Journal of Bioethics, 9, 48–49.PubMedCrossRefGoogle Scholar
  58. Smith, Y., van Goozen, S., Kuiper, A., & Cohen-Kettenis, P. (2005a). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35, 89–99.PubMedCrossRefGoogle Scholar
  59. Smith, Y., van Goozen, S., Kuiper, A., & Cohen-Kettenis, P. (2005b). transsexual subtypes: Clinical and theoretical significance. Psychiatry Research, 137, 151–160.PubMedCrossRefGoogle Scholar
  60. Socarides, C. (1969). The desire for sexual transformation: A psychiatric evaluation of transsexualism. The American Journal of Psychiatry, 125, 1419–1425.PubMedGoogle Scholar
  61. Socarides, C. (1970). A psychoanalytic study of the desire for sexual transformation (´transsexualism´): The plaster-of-paris man. International Journal of Psychoanalyses, 51, 341–349.Google Scholar
  62. Socarides, C. (1988). The preoedipal origin and psychoanalytic therapy of sexual perversions. Madison: International Universities Press.Google Scholar
  63. South, S., Reichborn-Kjennerud, T., Eaton, N., & Krueger, R. (2012). Behavior and molecular genetics of personality disorders. In T. Widiger (Ed.), The Oxford handbook of personality disorders (pp. 143–165). Oxford: Oxford University Press.Google Scholar
  64. Stoller, R. (1996). The gender disorders. In I. Rosen (Ed.), Sexual deviation (3rd ed., pp. 111–133). Oxford: Oxford University Press.Google Scholar
  65. Terada, S., Matsumoto, Y., Sato, T., Okabe, N., Kishimoto, Y., & Uchitomi, Y. (2012). Suicidal ideation among patients with gender identity disorder. Psychiatry Research, 200, 469–474.PubMedCrossRefGoogle Scholar
  66. Torgersen, S. (2012). Epidemiology. In T. Widiger (Ed.), The Oxford handbook of personality disorders (pp. 186–205). Oxford: Oxford University Press.Google Scholar
  67. Trull, T., Scheiderer, E., & Tomok, R. (2012). Axis II Comorbidity. In T. Widiger (Ed.), The Oxford handbook of personality disorders (pp. 219–236). Oxford: Oxford University Press.Google Scholar
  68. Volkan, V., & Greer, W. (1996). True transsexualism. In I. Rosen (Ed.), Sexual deviation (3rd ed., pp. 158–173). Oxford: Oxford University Press.Google Scholar
  69. Wallien, M. (2008). Gender dysphoria in children: Causes and consequences. Unpublished Academic dissertationGoogle Scholar
  70. World Professional Association for Transgender Health. (2011). Standards of care for the health of transsexual, transgender and gender non-conforming people, 7th Version. http://www.wpath.org/. Accessed January 2013.
  71. Zucker, K., & Bradley, S. (1995). Gender identity disorders and psychosexual problems in children and adolescents. New York: Guilford Press.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Luk Gijs
    • 1
    • 2
  • Ellis van der Putten-Bierman
    • 1
  • Griet De Cuypere
    • 3
  1. 1.Department of Medical Psychology, Center of Expertise on Gender DysphoriaVU University Medical CenterAmsterdamThe Netherlands
  2. 2.Institute of Family and Sexuality StudiesKU LeuvenLeuvenBelgium
  3. 3.Center of Sexology and Gender ProblemsUniversity Hospital GhentGhentBelgium

Personalised recommendations