Risk Factors and Clinical Correlates of the Treatment Pathway for People with Gender Dysphoria

Abstract

There is an increasing awareness and visibility of transgender people, particularly in Europe and North America. Compared to the non-trans general population transgender people remain a vulnerable group with higher levels of mental health problems due to existing discrimination and victimization as well as lack of adequate treatment options and legal protection in most countries.

This thesis consists of 5 studies to examine risk factors and clinical correlates of the treatment pathway of transgender people. The studies looked specifically at prevalence of transsexualism and mental health correlates, including Non-Suicidal Self-Injury (NSSI), body dissatisfaction and anxiety in transgender people as a population, but also as separate groups (young and older transgender people).

An overall meta-analytical prevalence for transsexualism of 4.6 in 100,000 individuals was found; 6.8 for trans women and 2.6 for trans men, which suggests a sex ratio of trans females to trans males of 2.62 to 1. More importantly, time analysis found a clear increase in reported prevalence over the last 50 years, which highlights the need to plan for expansion of transgender health services and training and education for a future workforce in this field.

A lifetime presence of Non-Suicidal Self-Injury (NSSI) of nearly half of all young transgender patients was founds and more than a quarter reported current NSSI. Risk factors for current and lifetime Non-Suicidal Self-Injury (NSSI) in young transgender people are being a trans male and having greater psychopathology. General psychopathology could be predicted by transphobic experiences, low self-esteem, and interpersonal problems.

Transgender individuals exhibit greater body dissatisfaction than cisgender controls and, importantly, transgender men have comparable body dissatisfaction scores to cisgender men with an eating disorder. In relation to the roots of their body dissatisfaction, both transgender men and transgender women experience greatest dissatisfaction not only with gender-identifying body parts, but also with body shape and weight. Transgender men may be at particular risk for the development of maladaptive eating behaviours and other body image-related behaviours.

The vast majority of older people presenting at transgender health services over the age of 50 years old are transgender females, with a sex ratio of transgender females to transgender males of 23.7:1. The use of cross-sex hormones prior to seeking treatment is widespread among transgender females and appears to be associated with psychological benefits.

There are high rates of possible (32.8%) and probable (36.0%) current anxiety disorder in untreated transgender people attending a transgender health service. Transgender people have an almost 3-fold increased risk of probable anxiety disorder compared with the cisgender general population. Trans males show higher rates of possible and probable anxiety disorder (71.1%) than trans females. Low self-esteem and interpersonal functioning are predictors of anxiety disorder in the transgender population, which highlights the importance of psychological intervention and support.

El número de individuos que se identifica como transgénero ha aumentado en los últimos años en Europa y Norteamérica. Esta tesis consiste en 5 estudios que examinan los factores de riesgo y las características psicológicas de las personas transgénero, que acceden a servicios de salud porque requieren una transición médica. El primer estudio describe una prevalencia de transexualismo de 4.6 por cada 100,000 personas, 6.8 para mujeres transgénero y 2.6 para hombres. Esto sugiere que existen 2.6 mujeres transgénero por cada hombre. Es importante destacar que al analizar la evolución a lo largo del tiempo se demuestra un incremento en la prevalencia, año tras año, durante los últimos 50 años, lo que sugiere la importancia de aumentar los servicios de salud para estas personas, así como mejorar la educación de los profesionales de la salud. El siguiente estudio demuestra que la presencia de auto lesiones durante la vida, en esta población, es de casi de un 50% entre la población joven, siendo un 25% la tasa de auto lesiones, en el momento actual. Los factores de riesgo de auto lesiones están relacionados con ser hombre transgénero y presentar una elevada psicopatología. Experiencias transfóbicas, baja estima personal, y problemas interpersonales predicen una alta psicopatología. El tercer estudio describe como las personas transgénero presentan una mayor insatisfacción corporal que las personas que no son transgénero (cis género). Los hombres transgénero experimentan una insatisfacción corporal muy similar a los hombres cis género, con trastornos de la alimentación. El cuarto estudio se centra en las personas transgénero mayores de 50 años, y demuestra que el ratio de mujeres a hombres (transgénero) es 23.7:1. Este estudio también demuestra que las hormonas tienen beneficios psicológicos. El último estudio demuestra que las personas transgénero tienen 3 veces más riesgo de padecer ansiedad que las personas no trans. Baja estima personal y problemas interpersonales predicen ansiedad en las personas transgénero, lo que señala la importancia de las intervenciones psicológica en estas personas.