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Sociodemographic, Clinical, and Psychiatric Characteristics of Transsexuals

from Spain

Article  in  Archives of Sexual Behavior · March 2008

DOI: 10.1007/s10508-007-9307-8 · Source: PubMed

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Arch Sex Behav
DOI 10.1007/s10508-007-9307-8

ORIGINAL PAPER

Sociodemographic, Clinical, and Psychiatric Characteristics

of Transsexuals from Spain
Esther Gómez-Gil Æ Antoni Trilla Æ Manel Salamero Æ
Teresa Godás Æ Manuel Valdés

Received: 8 November 2006 / Revised: 13 June 2007 / Accepted: 4 August 2007

Ó Springer Science+Business Media, LLC 2008

Abstract The aim of this study was to examine the char- their parents and the higher proportion of MFs who reported
acteristics of transsexuals from Spain. A total of 252 consec- same-sex sexual orientation compared with previous studies.
utive applicants for sex reassignment were evaluated using a
standardized semistructured clinical interview and the Mini Keywords Transsexualism
Gender identity disorder

International Neuropsychiatric Interview (Spanish Version Sexual orientation
Psychiatric comorbidity
Spain
5.0.0) to record demographic, clinical, and psychiatric data.
Transsexualism was diagnosed in 230 patients, with a male
to female (MF)/female to male (FM) ratio of 2.2:1. Trans- Introduction
sexual patients frequently had low employment status, lived
with their parents, and mainly had a sexual orientation The results of epidemiological and clinical research on
toward same-sex partners. The most frequent psychiatric transsexualism have been published in several countries.
diagnoses were adjustment disorder and social phobia in Descriptive data from Australia, Belgium, Canada, Denmark,
both groups, and alcohol and substance-related disorders in Germany, The Netherlands, Northern Ireland, Norway,
the MF group. MF transsexuals were older than FM tran- Poland, Singapore, Sweden, Switzerland, United Kingdom,
sexuals when requesting sex reassignment, but did not differ United States, and the former Yugoslavia have shown differ-
in age when starting hormonal therapy (often on their own); ences in sex ratio, sociodemographic and clinical features, and
fewer MFs were in employment requiring high educational psychiatric comorbidity (Table 1). Differences in these fea-
qualification, more were non-Spanish natives, and more had tures have also been reported between male to female
previous and current histories of alcohol and substance abuse transsexuals (MFs) and female to male transsexuals (FMs).
or dependence. The basic characteristics of transsexuals Several studies have found that FMs have more stable occu-
from Spain were similar to those of other European coun- pations, are better adjusted socially, and present less psy-
tries, except for the higher proportion of patients living with chopathology than MFs (for a review, see Lothstein, 1984;
Michel, Mormont, & Legros, 2001). However, there is little
information regarding the presentation of gender identity
disorders (GID) in Spain (Bergero et al., 2001; Esteva de
E. Gómez-Gil (&)
M. Valdés
Department of Psychiatry, Institute of Neurosciences, Hospital
Antonio et al., 2001; Giraldo, Esteva, & Bergero, 2001;
Clı́nic, University of Barcelona, Villarroel 170, 08036 Gómez-Gil et al., 2006).
Barcelona, Spain In Spain, Andalusia was the first autonomous region to
e-mail: [email protected] create a unit for gender identity disorders, which opened in
A. Trilla
1999. In this region, complete coverage of medical and surgical
Clinical Epidemiology Unit, Hospital Clı́nic, University of treatment of patients with GID is offered under the public health
Barcelona, Barcelona, Spain system (Esteva de Antonio et al., 2002). In the rest of Spain, the
costs of surgical procedures are not currently covered by the
M. Salamero
T. Godás
Department of Psychology, Institute of Neurosciences, Hospital
public health system (Gómez-Gil & Esteva de Antonio, 2006;
Clı́nic, University of Barcelona, Barcelona, Spain Gómez-Gil & Peri-Nogués, 2002). In the autonomous region of

123
 Table 1 Summary of selected previous studies of transsexualism
Study Method Results of parameters compared with our study

123
Australia
Ross, Wålinder, Lundström, Questionnaires sent to all psychiatrists in Australia, asking how MF:FM sex ratio: 6.1:1
and Thuwe (1981) many transsexuals had been seen in the preceding 2 years
(272 transsexuals)
Belgium
De Cuypere, Jannes, and Psychological and psychiatric evaluation to 65 applicants at a MF:FM sex ratio: 1.7:1
Rubens (1995) Gender Identity Clinic. Thirty-five met diagnosis for No diagnosis of transsexualism: 30 of 65 participants excluded
transsexualism and were admitted to the program for SR
Applying for SRS before age 30: more FMs (84.6%) than MFs (31.8%)
therapy (22 MFs and 13 FMs)
Education: more basic and lower secondary in MFs (68.2%) than in FMs (38.3%),
but the difference was not significant
Employment: more FMs (84.6%) were employed or were students than MFs
(54.5%)
Partner: more stable relationships in FMs (53.8%) than in MFs (27.3%)
Previous marriage with opposite sex: more frequent in MFs (45%) than FMs (0%)
Sexual orientation: more MFs (27.3%) with heterosexual preference than
FMs (0%)
Axis I comorbidity: higher percentage in MFs (22.7%) than in FMs (0%)
Previous psychiatric treatment: similar in MFs (45.1%) and FMs (28.5%)
Previous abuse or alcohol and/or drugs: similar in MFs (50%) and FMs (61.5%)
De Cuypere et al. (2007) Demographic questionnaires completed for 412 transsexuals MF:FM sex ratio: 2.43:1
who had undergone SRS Mean age when requesting SR: MFs (32.7 years) older than FMs (28.5 years)
Education: most had reached first years of secondary school (98%) or last years
of secondary school (65%), and only 19% had a degree from a university
or college or further education. No differences between sexes were found
Employment: more MFs were unemployed (52%) than FMs (35%)
Partner: 40% had a partner (married or living together) at first consultation
Previous marriage with opposite sex: more in MFs (19%) than in FMs (4%)
Canada
Blanchard, Clemmensen, Chart and questionnaires of 136 males and 73 females with MF:FM sex ratio: 1.7:1
and Steiner (1987) complaints of gender dysphoria, after excluding 12 cases No diagnosis of transsexualism: eight out of 136 (5.8%)
Partner: 46.2% of males and 49.3% of females had cohabited with a partner
of the same biological sex
Sexual orientation: more males (73/136) were with sexual preference for the
opposite biological sex (heterosexual) than females (1/73)
Previous hormonal therapy: before presenting at the clinic, 45.6% of males
and 8.3% of females had taken sex hormones
Arch Sex Behav
 Table 1 continued
Study Method Results of parameters compared with our study

Denmark
Arch Sex Behav

Sorensen and Hertoft (1982) 29 MF and 8 FM transsexuals with SRS and a change in legal MF:FM sex ratio: 3.6:1
status in Denmark Sexual orientation: most of MFs felt sexually attracted to men, but one third had
heterosexual experience, mainly occasional relations. More MFs had a sexual
preference for the opposite sex than FMs. About 17% had never participated in
either homosexual or heterosexual activity
Germany
Köckott and Fahrner (1988) Personal interview and follow-up study in 58 transsexuals Mean age when requesting SRS: MFs (24.9 years) younger than FMs (32.1 years)
(37 MF and 21 FM) in order to report differences betwen Partner: FMs more likely to be in a lasting partnership (10/37) than MFs (12/21)
sexes
Previous marriage with opposite sex: similar married and divorced in MFs (33%)
and FMs (24%)
Sexual orientation: only 6 of 10 partners belonged to the same biological sex
in MFs whereas all 12 partners of the FMs belonged to the same biological sex
Weitze and Osburg (1996) Examination of 1422 legal decisions regarding persons seeking MF:FM sex ratio: 2.3:1
legal recognition of their change in sex Mean age when requesting legal change of first name or of sex status: higher
for MFs (34 years) than FMs (30 years)
Garrels et al. (2000) Data study derived from 1758 transsexuals diagnosed between MF:FM sex ratio: 2:1 (from 1970 to 1994) and 1.2:1 (from 1994 to 1998)
1964 and 1998 in Germany
The Netherlands
Verschoor and Poortinga Clinical interviews of 168 males and 55 females requesting SRS MF:FM sex ratio: 3.38:1
(1988) and undergoing hormonal treatment for at least 3 months Applying for SRS before age of 30: 51.2% of MFs and 72.7% of FMs
Employment: more FMs (74.5%) were employed in job or student than MFs
(57.6%)
Partner: more FMs were in stable relationships (48.0%) than MFs (21.1%)
Previous marriage with opposite sex: MFs more (27.5%) than FMs (0)
Sexual orientation: more MFs (23.7%) have exclusively sexual experience
with the opposite biological sex than FMs (2.4%)
Previous mental disorders: higher prevalence of previous abuse of alcohol
and drugs in MFs (11.3%) than in FMs (3.8%)
Bakker, van Kesteren, Participants selected from registers of 713 Dutch-born MF:FM sex ratio: 2.5:1
Gooren, and Bezemer transsexuals Foreign origin: 6.9%
(1993)
van Kesteren, Gooren, and Medical records of 1285 subjects with complaints of gender MF:FM sex ratio: 3:1
Megens (1996) dysphoria (1975–1992) No diagnosis of transsexualism: 6% of males and 4% of females were not eligible
Mean age when requesting SR: women with gender dysphoria seek treatment
between the ages of 20 and 25, on average 5 years earlier than men (most
between 25 and 30 years)
Foreign origin: 158 foreign patients (12.3%); among them, fewer women with
gender dysphoria (18%)

123
 Table 1 continued
Study Method Results of parameters compared with our study

123
Cohen-Kettenis and van Follow-up study of 22 consecutive adolescent transsexuals Employment: 43% were students, 36% were working, and 21% were unemployed
Goozen (1997) (7 MF and 15 FM) who underwent SRS Living arrangements: most participants (79%) lived independently or in student
dormitories, 14% with their partner, and 7% with their parents
Partner: 36% had a stable relationship with a partner
Smith, van Goozen, Kuiper, Self-reported sexual preference of 187 transsexuals eligible Mean age when requesting SR: MFs applying for SR later (28.3 years in
and Cohen-Kettenis for SR homosexuals and 36.8 in nonhomosexuals) than FMs (24.4 years in
(2005) homosexuals and 23.8 in nonhomosexuals)
Previous marriage with opposite sex: fewer FMs (14.9%) were or had been
married than MFs (33.0%)
Sexual orientation: from the total, 113 transsexuals (61 MFs and 52 FMs) had
sexual preference for the same biological sex and 74 (52 MFs and 22 FMs)
had nonhomosexual preference
Northern Ireland
O’Gorman (1982) Epidemiological and clinical retrospective study of 28 MF:FM sex ratio: 3:1
transsexuals (21 males and 7 females) Mean age when requesting SRS : MFs (26.7 years) were older than FMs
(24.5 years)
Employment: 15 MFs and three FMs were employed
Previous marriage with opposite sex: seven MFs and two FMs were married
or divorced
Axis I comorbidity: 11 MFs and 3 FMs had a history of psychiatric illness,
including psychotic episodes, acute transient disturbances, anorexia nervosa,
and depression
Sexual orientation: eight females and four females had had sexual experience
with members of the same biological sex. 13% of MFs never participated in
any sexual activity
Norway
Haraldsen and Dahl (2000) Interviews and the SCL-90 administered to 86 transsexuals MF:FM sex ratio: 1.1:1
Axis I comorbidity: the most prevalent were major depression (17.4%), anxiety
disorders (18.6%), and substance abuse (16.2%). Others included dysthymia
(4.7%), bipolar disorder (2.3%), and eating disorder (1.2%)
Axis II comorbidity: cluster B were more prevalent (8.1%) than A and C (5.8%)
Poland
Godlewski (1988) Analysis dealing with diagnoses of transsexualism in 716 MF:FM sex ratio: 1:5.5
patients requiring sexological treatment
Arch Sex Behav
 Table 1 continued
Study Method Results of parameters compared with our study

Herman-Jeglińska, Psychological and sex-role assessment of 29 MF and 103 FM MF:FM sex ratio: 1:5.42
Grabowska, and Dulko applicants for hormonal therapy or SRS, classified as primary
Arch Sex Behav

Mean age when requesting SR: secondary MFs were older (35.9) than primary
(2002) versus secondary transsexual typology MFs (21.8), secondary FMs (24.8), and primary FMs (23.1 years)
Education: in general transsexuals reached secondary school. The secondary MFs
were significanly better educated than the other groups
Previous marriage with opposite sex: none of the primary MFs or FMs had been
married, whereas 54% of secondary MFs and 19% of secondary FMs had been
married
Singapore
Tsoi (1992) Developmental profile of 320 MFs and 130 FMs when applying Mean age when requesting SRS: on average the MFs were about 1 year younger
for SRS in Singapore (23.5 years) than the FMs (24.9 years)
Education: more FMs (23%) had post-secondary education than MFs (16%)
Employment: more MFs were in lower occupational class than FMs. More MFs
(8%) are unemployed than FMs (2%). History of prostitution in 38% of MFs
Previous marriage with opposite sex: none had ever married
Sexual orientation: among the sexually active group (87% of the total), all were
homosexual
Spain
Esteva de Antonio et al. Interview and questionnaires to the 100 first patients MF:FM sex ratio: 2.1:1
(2001) (71 MFs and 29 FMs) No diagnosis of transsexualism: 14%
Mean age when requesting for SR: 29.8 years
Starting hormone without prescription: 56% of applicants
Bergero Miguel et al. (2001) Interview and questionnaires to the 100 first patients Education: 58.8% had low educational level
(71 MFs and 29 FMs) Employment: 55.9% reported job discrimination
Partner: 21.5% lived with a partner
Foreign origin: 2%
Previous psychiatric treatment: 25.6%
Previous psychological assessment: 53.5%
Gómez Gil et al. (2006) Estimation of the epidemiology of transsexualism in Catalonia MF:FM sex ratio: 2.6
according to health care demand Prevalence rate in Catalonia: 1:21,031 males and 1:48,096 females
Annual incidence in Catalonia: 0.73/100,000/year
Sweden
Bodlund, Kullgren, Assessment of Axis I disorders using clinical interviews Employment: about 65% of transsexuals were at work or studying. The rest were
Sundbom, and Höjerback in 19 transsexuals (9 MF and 10 FM) unemployed or on long-term sick leave
(1993) Axis I comorbidity: other Axis I diagnosis in 10 of 19 patients; there were 5 with
adjustment disorders, 2 with anxiety disorder, 2 with alcohol abuse, and 1 with
delusional syndrome

123
 Table 1 continued
Study Method Results of parameters compared with our study

123
Landén, Wålinder, and Retrospective and cross-sectional study of files of 233 Mean age when requesting SRS: MFs older (32.2 years) than FMs (29.3 years)
Lundström (1998) transsexuals (134 FM and 99 FM) who applied for SRS Education: no differences in the level of education
in Sweden during the period 1972–1992
Employment: 69.8% of MFs and 62.5% of FMs were employed
Previous marriage with opposite sex: more frequent in MFs (23.1%) than in FMs
(6.1%)
Foreign origin: no significant differences between MFs (24.6%) and FMs (22.2%)
Sexual orientation: more MFs were bisexual (10.7%) or attracted to the opposite
sex (9.1%) than FMs (0% and 1.1%, respectively)
Axis I comorbidity: mood disorders similar for MFs (12.7%) and FMs (7.1%),
psychotic disorder similar for MFs (2.2%) and FMs (4.1%)
Previous abuse of alcohol and/or drugs: similar in MFs (11.9%) and FMs (18.2%)
Previous psychiatric treatment: similar in MFs (38.8%) and FMs (35.4%)
Olsson and Möller (2003) Information from 402 applications for SR in Sweden since 1965, MF:FM sex ratio: 1.2:1: for period 1965–1985, 1.8:1: for period 1986–2002
comparing various time periods Mean age when requesting SRS: MFs were older in the last two decades (32.2 and
36.6 years) than FMs (29.3 and 30 years)
Foreign origin: similar percentage in MFs (24–25%) and FMs (24–27%)
Switzerland
Hepp, Kraemer, Schnyder, Structured clinical interviews in 20 MFs and 11 FMs Axis I comorbidity: no additional current Axis I diagnosis were found in 60%
Miller, and Delsignore of MFs and 63.6% of FMs. Main diagnosis were 8 with anxiety disorders,
(2005) 4 with mood disorders, 3 with substance-related disorders, and 3 with
somatoform disorders
Previous mental disorders: non lifetime Axis I diagnosis were found in 20% of
MFs and 45.5% of FMs. Main diagnoses were 14 with mood disorders, 14 with
substance-related disorders, 7 with anxiety disorders, 2 with psychotic
disorders, and 1 with eating disorders
United Kingdom
Burns, Farrel, and Brown Clinical features of 77 transsexuals and 29 nontranssexuals MF:FM sex ratio: 3.1:1
(1990) attending a gender-identity clinic Mean age when requesting SR: 32.6 years
No diagnosis of transsexualism: 27.35%
Sexual orientation: more MFs (45%) were heterosexual than FMs (13%)
Arch Sex Behav
 Table 1 continued
Study Method Results of parameters compared with our study

United States
Arch Sex Behav

Dixen, Maddever, Van Interviews and questionnaires in 479 male and 285 female Mean age when requesging SRS: MFs (29 years) were older than FMs
Maasdam, and Edwards applicants for SRS (27.3 years)
(1984) Employment: 63.5% of MFs and 75.4% of FMs were employed. 24.4% of MFs
and 10.8% of FMs were receiving benefits. 16.9% of MFs worked as prostitutes
Living with family: 16% of MFs and FMs
Partner: fewer MFs (28.8%) lived with partners (lover or spouse) than FMs
(46.2%). Fewer MFs (30.7%) had a current partner of the same biological sex
than FMs (63.5%)
Previous marriage with opposite sex: more frequent in MFs (21%) than in FMs
(11.4%)
Sexual orientation: more MFs (10%) had current partner of the opposite biological
sex than FMs (2%)
Cole, O’Boyle, Emory, and Evaluation of 435 gender dysphoric individuals (318 males and Mean age when requesting SR: MFs older (33 years) than FMs (30 years)
Meyer (1997) 117 females) to evaluate Axis I DSM-IV diagnosis Education: no statistical differences between MFs and FMs. Primarily between
high school graduate and partial college
Employment: no statistical differences between MFs and FMs. Primarily middle
class
Axis I comorbidity: similar percentage in MFs (6%) and FMs (4%). Major
depression was the most common diagnoses, bipolar disorder and
schizophrenia were also represented
Previous mental illness: only 9% indicated past treatment for diagnosed
psychiatric conditions other than gender dysphoria or substance abuse
Substance abuse history: similar percentage in MF (29%) and FM (26%)
Lawrence (2005) Self-administered questionnaire about sexuality before and after Mean age after requesting SRS, at time of survey: 44 years (range, 18–70 years)
SRS reported by 232 MFs Sexual orientation: before SRS, 54% of MFs had been predominantly attracted
to women and 9% had been predominantly attracted to men. After SRS, these
figures were 25% and 34%, respectively
Former Yugoslavia
Rakic, Starcevic, Maric, and Standardized questionnaires 22 MFs and 10 FMs after SRS Mean age when requesting SRS: MFs (24 years) younger than FMs (27 years)
Kelin (1996) Employment: similar in MFs (32%) and in FMs (40%) before SRS
Partner: 27% of MFs and 40% of FMs had a sexual partner before SRS
Note: MFs = male to female transsexuals; FMs = female to male transsexuals; SR = sex reassignment; SRS = sex reassignment surgery; SCL-90 = symptom checklist 90; Sexual orientation:
patients were considered heterosexual if they reported sexual attraction or preference to members of the opposite biological sex and homosexual if they reported sexual attraction or preference to
members of the same biological sex

123
 Arch Sex Behav

Catalonia, the Hospital Clı́nic of Barcelona is the sole public fourth edition of the Diagnostic and Statistical Manual of
hospital that provides specialized, comprehensive psychiatric- Mental Disorders (DSM-IV; American Psychiatric Associa-
psychological and endocrine therapy for transsexual patients. tion, 1994) and the tenth revision of the ICD Classification of
Since 1990, the vast majority of applicants for sex reassignment Mental and Behavioural Disorders (ICD-10; World Health
in this region have been referred to this hospital by endocri- Organization, 1992) was made after several sessions with both
nologists, private surgeons, psychiatrists, and general prac- mental health professionals. Patients who satisfied the DSM-
titioners (Gómez-Gil et al., 2006). Since May 2006, the IV criteria for GID in adolescence or adulthood or ICD-10
Hospital Clı́nic has also been officially accredited as a referral criteria for transsexualism were provided psychotherapy and
unit for gender identity disorders. started real-life experience trials. Those who met the eligi-
In view of the scarcity of data from southern European bility and readiness requirements in the guidelines of the
countries and because we believe that the divergences in Standards of Care of the Harry Benjamin Gender Dysphoria
some of the data published may be due to cultural factors, we Association (Meyer et al., 2001) were issued a final certificate
designed the present study to define the characteristics of by the two professionals recommending hormone therapy or
applicants for sex reassignment in Spain. FMs and MFs were surgery. Endocrine treatment is provided at this hospital under
also compared on variables related to sociodemographic, the National Health Service but surgical treatment is only
clinical, and psychiatric characteristics. available privately. If patients did not satisfy the criteria for
GIDs, another Axis I or II diagnosis was made according to
DSM-IV and ICD-10 criteria. The presence of psychiatric
Method comorbidity in transsexual patients does not necessarily rule
out hormonal therapy or surgery, but some diagnoses may
Participants delay or preclude treatment. Appropriate therapy and psy-
chotropic medication are offered to all patients for psychiatric
The study population comprised 230 transsexual patients comorbidities or other differential diagnoses.
(159 MF and 71 FM). This sample was selected from a total
of 252 patients with complaints of gender dysphoria who
contacted the Hospital Clı́nic (Barcelona, Spain) from the Mini International Neuropsychiatric Interview (M.I.N.I),
year 2000 until April 2006 to apply for hormonal or surgical Spanish Version 5.0.0
sex reassignment treatment.
The Mini International Neuropsychiatric Interview (M.I.N.I)
(Sheehan et al., 1998), Spanish Version 5.0.0. (Bobes et al.,
Measures and Procedure 1997), was performed by the psychiatrist to assess psychiatric
comorbidity. We used this short structured diagnostic interview
Standard Clinical Assessment for the assessment of the main DSM-IV Axis I psychiatric dis-
orders and the Axis II antisocial personality disorder. As the
Every patient completed semistructured clinical interviews M.I.N.I. does not include lifetime history diagnoses of agora-
lasting between 1 and 2 h by a psychiatrist and a psychologist phobia, generalized anxiety disorder, alcohol and substance
with several years of experience in diagnosis of GID. Soci- abuse/dependence, anorexia, and bulimia nervosa, questions
odemographic, clinical, and psychiatric data recorded are were added about lifetime experience of these conditions.
shown in Tables 2–4. Diagnostic assessment according to the Similarly, as the M.I.N.I. does not include adjustment disorders,

Table 2 Differential diagnoses

ICD-10 and DSM-IV-TR diagnoses Male n Female n
in the total cohort of male and
female applicants for sex Gender identity disorder
reassignment
F64.0 transsexualism/gender identity disorder in adolescents or adults [302.85] 159 71
F64.1 dual-role transvestism/stress-related cross-dressing behavior [302.6] 5 –
F64.8/F64.9 other gender identity disorder and gender identity disorder, 5 3
Note: ICD-10 = The ICD-10 unspecified/gender identity disorder not otherwise specified [302.6]
classification of mental and Other psychiatric diagnoses without gender identity disorders
behavioural disorders, World
F20–29 schizophrenia and other psychotic disorders [295.xx–298.x] 2 1
Health Organization (1992)
F42 obsessive-compulsive disorder [308.3] 2 1
DSM-IV-TR = The diagnostic
and statistical manual of mental F66.0 sexual maturation disorder 1 –
disorders, American Psychiatric F60 personality disorders [301.x] 3 –
Association (1994)

123
Arch Sex Behav

Table 3 Comparison of sociodemographic, sexual, and hormonal characteristics of MF and FM Spanish transsexuals
Characteristic MFs (n = 159) FMs (n = 71) Mann–Whitney U rank sum test
M SD M SD Z p

Age at requesting SR 29.7 8.3 27.3 7.7 -2.2 .032

Age at onset of hormonal therapy 24.4 7.8 25.1 9.7 -1.8 ns

Charateristic MFs FMs Chi-square test

n (%) n (%) v2 P

Referral 20.9 <.001

General practitioner 35 (22.0) 26 (36.6)
Endocrinologist 28 (17.6) 12 (16.9)
Surgeon 77 (48.4) 13 (18.3)
Psychiatrist 12 (7.5) 13 (18.3)
Educational level 1.7 nsa
Primary school 46 (28.9) 20 (28.2)
Lower secondary school 47 (29.6) 19 (26.8)
Upper secondary school 31 (19.5) 11 (15.5)
Pre-university and unfinished 17 (10.7) 10 (14.1)
university studies
University graduate 18 (11.3) 11 (15.5)
Employment status 8.7 <.05
Employment requiring high educational 8 (5.0) 12 (16.9)
qualifications
Employment requiring low educational 115 (72.3) 45 (63.4)
qualifications
Unemployedb 25 (15.7) 12 (16.9)
Studentb 7 (4.4) 2 (2.8)
Social supportb 4 (2.5) 0 –
Living arrangements 4.7 ns
With parents 62 (39.0) 30 (42.3)
With partner 41 (25.8) 25 (35.2)
Alone 32 (20.1) 11 (15.5)
With friends 24 (15.1) 5 (7.0)
Previously married to a member 9 (5.7) 5 (7.0) – nsc
of the opposite sex
With biological children 5 (3.1) 1 (1.4) – nsc
Non-Spanish nativesd 40 (25.2) 6 (8.5) 7.6 <.001
From South America 38 (23.9) 2 (2.8)
From Europe 2 (1.3) 4 (5.7)
Residence 1.3 ns
Catalonia 141 (88.7) 68 (95.8)
Rest of Spainb 15 (9.4) 3 (4.2)
b
Other countries 3 (1.9) 0 –
Sexual orientation .7 ns
Same biological sex 143 (89.9) 67 (94.4)
Opposite biological sexb 7 (4.4) 0 –
Bisexualb 7 (4.4) 2 (2.8)
b
Unknown 2 (1.3) 2 (2.8)
No sexual experience 20 (12.6) 16 (22.5) 3.0 ns

123
 Arch Sex Behav

Table 3 continued
Charateristic MFs FMs Chi-square test
n (%) n (%) v2 P

Hormonal therapy
Receiving hormonal therapy at time of requesting sex change 104 (65.4) 10 (14.1) 49.7 <.001
Started taking hormones on their own without prescription 95 (59.7) 2 (2.8) 63.0 <.001
Note: MFs = male to female transsexuals; FMs = female to male transsexuals
a
p values are from Kruskal–Wallis test for educational level variable
b
Categories were collapsed for statistical analysis to obtain the expected values for at least 80% of cells greater or equal to five
c
p values are from Fisher’s exact test
d
Participants from Colombia, Ecuador, Brazil, Argentina, Dominican Republic, Venezuela, Cuba, Uruguay, Chile, Peru, Belgium, Germany,
Portugal, Poland, and Andorra

questions according to DSM-IV criteria about current and life- significant differences were observed in the level of education.
time history were also added. Significantly more FMs (16.9%) were in employment requir-
ing high educational qualifications (p < .05) than MFs (5.0%).
A total of 53 MFs (33.3%) reported involvement at present or
Data Analysis in the past in prostitution or sex-shows. Most patients (39.0%
of MFs and 42.3% of FMs) lived with their parents. Nine MFs
Data were analyzed by descriptive tests using the SPSS and 5 FMs had previously been married to a member of the
statistical software package, Version 12.0. The Kolmogorov opposite biological sex. Five MFs and 1 FM had biological
Smirnov test was used to evaluate the normality of quanti- children. Forty (25.2%) MFs were non-Spanish: 38 were from
tative variables. Between-group comparisons of quantitative South America and 2 from Europe. In contrast, in the FM group
variables were performed using the non-parametric Mann– only 6 (8.5%) were non-Spanish natives (p < .001). Regarding
Whitney U test. Between-group comparisons of categorical sexual orientation, 89.9% of MFs and 94.4% of FMs were
variables were performed using chi-square analysis; when sexually attracted to members of the same biological sex.
the expected values for at least 80% of cells were fewer than No differences were recorded with regard to the absence of
five appropriate categories were collapsed or the Fisher’s sexual experience. Hormonal therapy at time of requesting
exact test were used. The Kruskal–Wallis rank test was used sex change was more frequent in MFs (65.4%) than in FMs
to compare educational level. In order to control for the (14.1%) (p < .001). Significantly more MFs (59.7%) started
increased chance of a significant finding with multiple taking hormones on their own without prescription than FMs
comparisons, only the most relevant variables were analyzed (2.8%) (p < .001).
(see Tables 3 and 4) and a significance level of p < .05 was Percentages of current and lifetime history of the main
set for each comparison. DSM-IV mental disorders are shown in Table 4. The most
frequent diagnosis was lifetime history of adjustment disorder
in MFs (56.0%) and in FMs (70.4%). Other frequent diagnoses
Results were current and lifetime history of alcohol and substance-
related disorders in the MF group, and lifetime history of
Differential diagnoses in the total cohort of male and female generalized anxiety disorder and current social phobia in both
applicants for sex reassignment are summarized in Table 2. groups. The MF group more frequently had a diagnosis of
The MF:FM sex ratio of transsexualism was 2.2:1. Twenty- current alcohol and current and/or lifetime substance abuse
three (9.1%) patients did not meet DSM-IV criteria for GID. or dependence (p < .05) than FMs. No differences between
Table 3 shows the sociodemographic, sexual, and hor- groups were found in reporting previous psychiatric treatment.
monal characteristics of the transsexual patients. MFs were
significantly older (M = 29.7 years, SD = 8.3) than FMs
(M = 27.3 years, SD = 7.7) when they requested sex reas- Discussion
signment in our unit (p < .05), but the groups did not differ in
terms of the age when hormonal therapy was started. MFs were Most of the results of this study corroborate data published in
referred mainly by private surgeons and FMs by general previous research (Table 1), but the transsexuals from Spain
practitioners and endocrinologists (p < .001). No statistically also present certain differences. Our MF:FM ratio (2.2:1) was

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Table 4 Comparison of the main DSM-IV mental disorders in MF and FM Spanish transsexuals assessed with the M.I.N.I. and with a Semi-
structured Psychiatric Interview Based on DSM-IV criteria
DSM-IV mental disorders MFs (n = 159) FMs (n = 71) Chi-square testa
n (%) n (%) v2 p

Mood and adjustment disorders

Major depression, past 2 weeks 5 (3.1) 2 (2.8)
Major depression, recurrent 2 (1.3) 0 –
Dysthymia, past 2 years 1 (.6) 2 (2.8)
Suicidal risk, past month 0 – – –
Mania and hypomania, current 0 – 0 –
Mania and hypomania, past 1 (.6) 0 –
Adjustment disorder, currentb 21 (13.2) 16 (22.5) 2.5 ns
Adjustment disorder, lifetimeb 89 (56.0) 50 (70.4) 11.7 <.001
Anxiety disorders
Panic disorder without agoraphobia, past month 5 (3.1) 2 (2.8)
Panic disorder, lifetime 9 (5.7) 6 (8.5)
Panic disorder with agoraphobia, past month 0 – 0 –
Agoraphobia without panic disorder, current 1 (.6) 0 –
Agoraphobia, lifetimeb 1 (.6) 3 (4.2)
Social phobia, past month 13 (8.2) 8 (11.3) .3 ns
Obsessive-compulsive disorder, past month 3 (1.9) 2 (2.8)
Post-traumatic stress disorder, past month 2 (1.3) 0
Generalized anxiety disorder, current 2 (1.3) 0
Generalized anxiety disorder, lifetimeb 14 (8.8) 4 (5.6) .3 ns
Substance-related disorders
Alcohol abuse/dependence, past 12 months 17 (10.7) 1 (1.4) 4.7 <.05
Alcohol abuse/dependence, lifetimeb 18 (11.3) 3 (4.2) 2.2 ns
Non-alcohol substance dependence/abuse, past 12 months 23 (14.5) 1 (1.4) 7.6 <.01
Non-alcohol substance abuse/dependence, lifetimeb 48 (30.2) 8 (11.3) 8.5 <.005
Psychotic disorders
Psychotic disorder, current 0 0
Psychotic disorder, lifetime 4 (2.5) 2 (2.8)
Eating disorders
Anorexia nervosa, current 1 (.6) 0
Anorexia nervosa, lifetimeb 2 (1.3) 1 (1.4)
Bulimia nervosa, current 0 – 0
Bulimia nervosa, lifetimeb 0 – 2 (2.8)
Antisocial personality disorder, lifetime 0 0
Previous psychiatric treatmentb 44 (37.6) 16 (34) .4 ns
Note: MFs = male to female transsexuals; FMs = female to male transsexuals; M.I.N.I. = Mini International Neuropsychiatric Interview
a
Chi-square test: the tests were omitted if there were fewer than 18 individuals in both groups
b
Supplementary psychiatric diagnosis added to the M.I.N.I. interview based on DSM-IV criteria

similar to that found in recent studies from Belgium (2.4:1) (De 2000), Norway (1.1:1) (Haraldsen & Dahl, 2000), and Sweden
Cuypere et al., 2007), The Netherlands (2.5:1) (Bakker et al., (1.8:1) (Olsson & Möller, 2003) show a slight predominance in
1993), from another Spanish region (2.1:1) (Esteva de Antonio the MF group and data from Australia (6.1:1) (Ross et al.,
et al., 2001), and to those found in most European countries, 1981) a substantial predominance. In contrast, FMs predomi-
the U.S., and Singapore (2–3:1) (for a review, see Landén, nate in Poland (1:5.5) (Godlewski, 1988; Herman-Jeglińska
Wålinder, & Lundström, 1996). Data from Canada (1.7:1) et al., 2002). In Spain, there are no epidemiological studies that
(Blanchard et al., 1987), Germany (1.2:1) (Garrels et al., refer to the whole population. Nevertheless, in Catalonia a

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trend towards an increase in the proportion of referrals among Since MF patients were referred mainly by the surgeon after
FMs has been noted in recent years (Gómez-Gil et al., 2006). requesting vaginoplasty, the proportion of sex-workers may
The percentage of patients who contacted our clinic but did have been overestimated as they constitute a subgroup with a
not present criteria for transsexualism (9.1%) was similar to the higher income level; on the other hand, this proportion may
percentage of non-eligibility estimated by the mental health have been underestimated because patients working in prosti-
professionals in an earlier Dutch study (van Kesteren et al., tution do not always seek genital sex reassignment.
1996) and higher than in a Canadian study (Blanchard et al., Several studies have found that FMs were more frequently
1987), but lower than rates found in other studies in Spain unpartnered at the time of diagnosis and were more often in
(Esteva de Antonio et al., 2001) and Belgium (De Cuypere stable relationships with same-sex partners (De Cuypere et
et al., 1995). al., 1995; Dixen et al., 1984; Köckott & Fahrner, 1988; Ver-
The mean age for requesting psychiatric assessment and schoor & Poortinga, 1988) than their MF counterparts. In our
sex reassignment treatment in our group was similar to that study, both groups lived predominately with their parents and
recorded at the other Spanish unit (Esteva de Antonio et al., there were no significant differences in the rate of partnership
2001) and in other European studies (Landén et al., 1998; van between sexes. An interesting aspect of our study was that in a
Kesteren et al., 1996). Several researchers found that FM few other countries do so many transsexuals (and nontrans-
applicants were younger when they applied for sex reassign- sexuals for that matter) still live with their parents (Cohen-
ment treatment (De Cuypere et al., 1995, 2007; Dixen et al., Kettenis & van Goozen, 1997). Another is that the frequency
1984; Landén et al., 1998; O’Gorman, 1982; Olsson & Möl- of previous marriage before sex reassignment was lower in our
ler, 2003; Smith et al., 2005; Verschoor & Poortinga, 1988; study than in the studies performed in Belgium (De Cuypere
van Kesteren et al., 1996; Weitze & Osburg, 1996), but not all et al., 2007), Germany (Köckott et al., 1988), The Nether-
(Rakic et al., 1996; Tsoi, 1990, 1992). In our study, FMs were lands (Verschoor & Poortinga, 1988), Poland (Herman-
younger when they came to our unit, but the groups did not Jeglińska et al., 2002), Sweden (Bodlund et al., 1993; Landén
differ in terms of age when starting hormonal therapy. This et al., 1998), and the U.S. (Dixen et al., 1984), which found
may be due, in part, to the fact that the rate of patients starting prevalence rates between 21% and 45% in the MF transsexual
hormonal therapy on their own in the MF subgroup was near group. In the Singapore study, none of the transsexuals had
60%. Moreover, endocrinologists tend to refer FMs for psy- ever married (Tsoi, 1990). Certain cultural features of the
chiatric evaluation when they request hormonal treatment, Spanish population (delayed independence of children, bar-
and surgeons tend to refer MFs when they request vagino- riers to employment, low level of information, and knowledge
plasty procedures. This suggests, in contrast to the results of in the family) may explain the high proportion of patients still
previous studies, that the groups were similar in age at the time living with their parents.
of starting hormonal sex reassignment. The frequency of applicants from foreign countries in our
In previous studies from Belgium (De Cuypere et al., 1995), study, 20%, was similar to that reported in the studies in The
The Netherlands (Verschoor & Poortinga, 1988), Singapore Netherlands (van Kesteren et al., 1996) and Sweden (Landén
(Tsoi, 1992), and the U.S. (Dixen et al., 1984), FMs were found et al., 1998; Olsson & Möller, 2003). In Catalonia, foreign
to have a significantly higher level of education and to be patients were mainly MFs from South American countries.
employed in more stable jobs than the MF group. The unstable Again, the unfavorable legal situation, a presumably lower
and low employment status in our population and in other level of social tolerance of MFs, and economic problems may
Spanish regions (Bergero Miguel et al., 2001), especially in the increase the likelihood of emigration from South America to
MF group, is a surrogate marker of the social exclusion that Spain, thus raising the prevalence of MFs in our country.
these patients suffer. The frequency of unemployment in our In agreement with the study by Tsoi (1992), we found
study population was similar to that found in the Swedish study sexual orientation to be mainly towards a same-biological sex
(Landén et al., 1998) and lower than that found in a study from partner. No significant differences were observed between
Belgium (De Cuypere et al., 2007), but the percentage of groups. One of the most interesting findings was the low
patients with social welfare support in our group was lower than percentage of MFs who reported sexual attraction to women or
in either study. The scarce support for publicly funded sex to both women and men (bisexual) in comparison to most
reassignment in Spain in recent decades has meant that only previous studies in Western Europe and the U.S. which have
patients with higher incomes have access to surgery in the reported percentages between 9% and 58% (Blanchard et al.,
private sector. Some patients who work as prostitutes may have 1987; Burns et al., 1990; De Cuypere et al., 1995; Dixen et
sufficient income to afford surgery (Dixen et al., 1984; Soren- al., 1984; Köckott & Fahrner, 1988; Landén et al., 1998;
sen & Hertoft, 1982; Tsoi, 1992). Among the MF transsexual Lawrence, 2005; Smith et al., 2005). These percentages seem
group, one third reported involvement (either at present or in to decrease after sex reassignment surgery (for a review, see
the past) in prostitution and/or sex-show work. The exact per- Lawrence, 2005), although the changes reported may be
centage of MFs who engage in sex work is difficult to calculate. inconsistent with observed patterns of physiological arousal

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(Lawrence, Latty, Chivers, & Bailey, 2005). One possible or dependence in the MF group with respect to the FM group
explanation for this difference is that in our study we asked found in our study was also reported by Hepp et al. (2005) and
about sexual attraction rather than history of sexual partner- by Verschoor and Poortinga (1988), but not by Landén et al.
ships or experience. Moreover, it is possible that in our study (1996). In contrast, the studies performed in Belgium (De
self-reports of sexual attraction in MFs overestimate the same- Cuypere et al., 1995) and the U.S. (Cole et al., 1997) found a
sex orientation because many gynephilic MFs may try to higher prevalence of previous substance abuse in both sexes
deceive their clinicians and inaccurately portray themselves as than in our study. The frequencies of previous psychiatric
androphilic to improve their chances of sex reassignment. This treatment in our study were similar to those obtained in
was undoubtedly a significant factor in the past and may Sweden (Landén et al., 1998), The Netherlands (Verschoor &
remain so today in countries such as Spain. Another possible Poortinga, 1988), and Belgium (De Cuypere et al., 1995). In
reason is that some MFs may misinterpret their sexual attrac- summary, in agreement with other studies (Cole et al., 1997;
tion to the thought or image of themselves as women (auto- De Cuypere et al., 1995; Hepp et al., 2005), our data suggest
gynephilia), rather than a genuine preference for the male that the prevalence of reported primary psychiatric problems
somatotype (Blanchard, 1989; Lawrence, 2005). In our view, is not high and that most patients had no additional current
it did not appear that the patients’ sexual orientation were Axis I diagnosis. Nevertheless, psychiatric difficulties in
similar to the autogynephilic images and fantasies described adjustment and substance-related disorders are extremely
by Blanchard (1989) and it is also possible that this aspect may relevant to the individual patient because they are likely to
differ between cultures; the prevalence of sexual attraction in have a negative influence on the experience of the sex reas-
MFs mostly towards males may be characteristic of Hispanic signment procedure. Prompt, adequate specialized attention
or Asiatic cultures. may help prevent or alleviate these secondary psychopathol-
In a previous study from Singapore (Tsoi, 1990, 1992), a ogies that may result from the enormous difficulties in coping
similar percentage of these patients in both groups had no sex with the gender dysphoria (Gómez-Gil & Peri-Nogués, 2002).
life and had never participated in either homosexual or heter- Our study had three main limitations. First, we lack
osexual activity, but clearly expressed their sexual orientation. information on comorbidity with personality disorders in
This is probably due to the difficulties that patients experience these patients. Work currently underway at our center aims to
before and during the transitional period. correct this. Second, the low prevalence found in some cat-
In agreement with previous research (Blanchard et al., egories, particularly in psychiatric diagnosis, meant that the
1987; Esteva de Antonio et al., 2001), we also found a high categories had to be grouped to make it possible to calculate
percentage of MFs who started taking hormones without the statistics for between-group comparisons. Finally, the sample
physician’s prescription. This practice, which may increase was not representative of all transsexuals since an unknown
the morbidity (Becerra, de Luis, & Piédrola, 1999), reflects the percentage of these patients do not undergo professional
problems that existed for many years in obtaining treatment in assessment. Nevertheless, we can assume that most patients
public hospitals in Spain and the intense discomfort felt by with GID living in our autonomous region were treated at the
these patients regarding their assigned sex. Hospital Clı́nic in Barcelona. The sample can, therefore, be
With regard to psychiatric comorbidity, the most prevalent regarded as representative of transsexual patients seeking
mental disorders in our sample were lifetime adjustment dis- professional treatment in accordance with the Standards of
order and social phobia in both groups, and alcohol and Care of the Harry Benjamin Gender Dysphoria Association
substance-related disorders in MF group. Haraldsen and Dahl (Meyer et al., 2001).
(2000) also found substance abuse, anxiety disorders, and Despite these limitations, the results of the present study
major depression the most prevalent diagnoses. Psychological suggest three things. First, transsexualism manifests itself
testing with our sample found that transsexuals lacked sig- differently in MFs and FMs. Social acceptance appears to be
nificant psychopathology, although a large number of MFs in lower for MFs and the repercussions greater, since these
the first stages of sex reassignment may experience more patients have lower employment status and are more likely to
psychological distress than patients in the later stages (Gómez- have alcohol and substance problems. Second, in spite of
Gil, Vidal-Hagemeijer, & Salamero, in press). Hormonal and cultural differences that may modulate the presentation and
surgical sex reassignment have been reported to improve behavioral expression of this condition, notable similarities
quality of life (Mate-Kole, Freschi, & Robin, 1988, 1990; are found between countries. Third, the results provide further
Newfield, Hart, Dibble, & Kohler, 2006). In agreement with support for the notion that transsexualism is not necessarily
the U.S. study by Cole et al. (1997) and with the Swiss study associated with severe comorbid psychiatric disorders. Spe-
by Hepp et al., (2005), the prevalence of primary disorders cialized gender psychiatrists and psychologists may be needed
such as psychotic disorders, major depression, bipolar disor- to help patients to confront difficulties during this vulnerable
der, or obsessive-compulsive disorder was not increased. The phase of their lives and to prevent much unnecessary mental
higher frequency of current and lifetime alcohol or drug abuse suffering.

123
 Arch Sex Behav

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