International Journal of Transgenderism

ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: http://www.tandfonline.com/loi/wijt20

Transgender and anxiety: A comparative study

between transgender people and the general
population

Walter Pierre Bouman, Laurence Claes, Nicky Brewin, John R. Crawford,

Nessa Millet, Fernando Fernandez-Aranda & Jon Arcelus

To cite this article: Walter Pierre Bouman, Laurence Claes, Nicky Brewin, John R. Crawford,
Nessa Millet, Fernando Fernandez-Aranda & Jon Arcelus (2016): Transgender and anxiety: A
comparative study between transgender people and the general population, International
Journal of Transgenderism, DOI: 10.1080/15532739.2016.1258352

To link to this article: http://dx.doi.org/10.1080/15532739.2016.1258352

Published online: 15 Dec 2016.

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Download by: [University of Newcastle, Australia] Date: 27 December 2016, At: 09:30
INTERNATIONAL JOURNAL OF TRANSGENDERISM
http://dx.doi.org/10.1080/15532739.2016.1258352

Transgender and anxiety: A comparative study between transgender people and

the general population
Walter Pierre Boumana, Laurence Claesb,c, Nicky Brewina,d, John R. Crawforde, Nessa Millete,
Fernando Fernandez-Arandaf,g, and Jon Arcelus a,h
a
Nottingham National Centre for Transgender Health, Nottingham, UK; bFaculty of Psychology and Educational Sciences, Katholieke Universiteit
Leuven, Leuven, Belgium; cFaculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; dSchool of Sport, Exercise, and
Health Sciences, Loughborough University, Loughborough, UK; eSchool of Psychology, University of Aberdeen, Aberdeen, UK; fDepartment of
Psychiatry, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain; gCIBER Fisiopatologıa de la Obesidad y Nutricion, ISCIII, Barcelona, Spain;
h
Division of Psychiatry and Applied Psychology, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK

ABSTRACT KEYWORDS
Background: Anxiety disorders pose serious public health problems. The data available on anxiety Anxiety; cross-sex hormone
disorders in the transgender population is limited by the small numbers, the lack of a matched treatment; gender dysphoria;
controlled population and the selection of a nonhomogenous group of transgender people. HADS; interpersonal
Aims: The aims of the study were (1) to determine anxiety symptomatology (based on the HADS) functioning; mental health;
self-esteem; transgender
in a nontreated transgender population and to compare it to a general population sample matched
by age and gender; (2) to investigate the predictive role of specific variables, including experienced
gender, self-esteem, victimization, social support, interpersonal functioning, and cross-sex hormone
use regarding levels of anxiety symptomatology; and (3) to investigate differences in anxiety
symptomatology between transgender people on cross-sex hormone treatment and not on
hormone treatment.
Methods: A total of 913 individuals who self-identified as transgender attending a transgender
health service during a 3-year period agreed to participate. For the first aim of the study, 592
transgender people not on treatment were matched by age and gender, with 3,816 people from
the general population. For the second and third aim, the whole transgender population was
included.
Measurements: Sociodemographic variables and measures of depression and anxiety (HADS),
self-esteem (RSE), victimization (ETS), social support (MSPSS), and interpersonal functioning (IIP-32).
Results: Compared with the general population transgender people had a nearly threefold
increased risk of probable anxiety disorder (all p < .05). Low self-esteem and interpersonal
functioning were found to be significant predictors of anxiety symptoms. Trans women on
treatment with cross-sex hormones were found to have lower levels of anxiety disorder
symptomatology.
Conclusions: Transgender people (particularly trans males) have higher levels of anxiety
symptoms suggestive of possible anxiety disorders compared to the general population. The
findings that self-esteem, interpersonal functioning, and hormone treatment are associated with
lower levels of anxiety symptoms indicate the need for clinical interventions targeting self-esteem
and interpersonal difficulties and highlight the importance of quick access to transgender health
services.

Transgender people are a diverse population of indi- identify and/or present in a way that is outside the
viduals who do not present and/or identify as the gen- gender dichotomy of man/woman (Richards et al.,
der they were assigned at birth either some or all of 2016).
the time (Richards & Barker, 2013). Transgender iden- Transgender people have been found to face a
tities include women and men who feminize or mas- number of difficulties and interpersonal challenges
culinize their bodies with cross-sex hormone (such as disclosing their gender identity) (Bockting &
treatment (CHT) and/or gender-confirming surgery Coleman, 2016). They have been found to suffer from
(GCS) and other gender-variant individuals who may high levels of discrimination and victimization (Claes

CONTACT Walter Pierre Bouman walterbouman@doctors.org.uk Nottingham National Centre for Transgender Health, 3 Oxford Street, Nottingham
NG1 5BH, UK.
© 2016 Taylor & Francis Group, LLC
2 W. P. BOUMAN ET AL.

et al., 2015; Kattari, Walls, Whitfield, & Langenderfer- symptomatology. However, the results are not consis-
Magruder, 2015; Leppel, 2016; Lombardi, Wilchins, tent (e.g., Reisner et al., 2015) and are limited by a
Priesing, & Malouf, 2001) and rejection from family small sample size (e.g., De Vries et al., 2014; Heylens
and loved ones (Koken, Bimbi, & Parsons, 2009). Pos- et al., 2014b) or by the lack of matched controls (e.g.,
sibly as a consequence, many transgender people have Colizzi et al., 2014; Davis & Colton Meier, 2014;
low self-esteem (Erich, Tittsworth, & Kerstein, 2010) Gomez-Gil et al., 2012).
and high prevalence rates of mental health problems, This study addresses the aforementioned limita-
particularly anxiety disorders and depression (Arcelus, tions of a small sample size, a lack of homogeneity,
Claes, Witcomb, Marshall, & Bouman, 2016; Bockting and a matched control group. The current study
et al., 2013; Claes et al., 2015; Davey, Bouman, Arce- investigates the prevalence of possible or probable
lus, & Meyer, 2014; Davey, Arcelus, Meyer, & Bou- anxiety disorder in a large cohort of adult transgender
man, 2016; Dhejne, Van Vlerken, Heylens, & Arcelus, people who seek treatment at a national transgender
2016; Heylens et al., 2014a; Marshall et al., 2016). health service; and the study compares this large
Research in the transgender population before treat- cohort of adult transgender people to general popula-
ment, using cross-sectional data, have shown high lev- tion data matched by age and gender (experienced
els of anxiety symptomatology in this population gender).
(Bockting et al., 2013; De Vries, Doreleijers, Steensma, This study has several aims: firstly, to determine the
& Cohen-Kettenis, 2011; Heylens et al., 2014a; Reisner levels of anxiety symptomatology suggesting possible
et al., 2015; Davey et al., 2016). High levels of anxiety and probable anxiety disorder in nontreated transgen-
symptomatology are particularly prevalent in transgen- der people and to compare them with a cisgender (cis)
der people before treatment (Bergero-Miguel et al., population matched by age and gender; and secondly,
2016; de Vries et al., 2011; Gomez-Gil et al., 2012; Hey- to investigate the predictive role for anxiety disorders
lens et al., 2014a). (possible and probable) of specific variables known to
Research looking at anxiety symptoms and anxiety be associated with anxiety symptoms in the cisgender
disorders in the transgender population have found and transgender population, such as age, gender, self-
an association with frequent experiences of discrimi- esteem, social support, interpersonal functioning and
nation in employment and housing, violence, physical victimization, and the use of CHT in transgender peo-
and verbal abuse, societal harassment related to gen- ple (Bouman et al., 2016a; Claes et al., 2015; Colizzi et
der presentation, perceived need to keep one’s trans- al., 2014; Davey et al., 2014; Davey, Bouman, Arcelus,
gender identity a secret, and lack of gender confirming & Meyer, 2015; G omez-Gil et al., 2012; Kessler, Chiu,
treatment (Bockting et al., 2013; Clements-Nolle, Demler, & Walters, 2005a; Kessler et al., 2005b;
Marx, & Katz, 2006; McNeil, Bailey, Ellis, Morton, & McLean, Asnaani, Litz, & Hofmann, 2011; Meier et
Regan, 2012). Some of these findings support the al., 2011). Finally, to investigate differences in anxiety
minority stress theory (Bockting et al., 2013; Meyer, scores between transgender people on cross-sex hor-
1995; 2003). However, these studies are limited by the mone treatment (CHT) with those not on cross-sex
small numbers of transgender people and heterogene- hormone treatment (non-CHT). For the last two aims
ity of the group (for instance, people at different stages the whole population of transgender people (on CHT
of transition). and not on CHT) will be selected.
Several studies have looked at the role of gender- Based on the literature regarding anxiety and trans-
confirming medical treatment (cross-sex hormone gender people, it was hypothesized that levels of anxi-
treatment [CHT] and gender affirming surgery ety will be higher in the transgender population
[GAS]) in anxiety symptoms among the transgender compared to the general population and associated
population (Bouman et al., 2016a; Colizzi, Costa, & with psychopathology, decreased self-esteem and
Todarello, 2014; Davis & Colton Meier, 2014; De Vries social support, discrimination, lower levels of interper-
et al., 2014; Dhejne et al., 2016; Gomez-Gil et al., 2012; sonal functioning, and lack of CHT treatment. There
Heylens, Verroken, De Cock, T’Sjoen, & De Cuypere, is no clear hypothesis regarding the relationship
2014b; Meier, Fitzgerald, Pardo, & Babcock, 2011). between gender and anxiety symptoms. Studies in the
These studies showed that gender-confirming medical general population suggest that cisgender women
treatment improves mental health, including anxiety present with higher levels of anxiety symptoms than
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 3

cisgender men, which may suggest that trans women Control group
present with higher anxiety symptoms too. There is, A total of 3,816 adults from the general population with
however, also the possibility that genetic factors play a an age range of 16 to 92 who participated in another
role in the aetiology of anxiety disorders and, conse- study (Crawford et al., 2009) was used as a control
quently, a predisposition to develop anxiety disorders group and matched by age and gender. These samples
may relate to one’s assigned gender at birth. were recruited between 2006 and 2009. In order to
increase the normative data, a broad representation of
the general adult UK population was selected in terms
Methods of the age, education, and gender (although, in most
cases, females were over-sampled). The recruitment
Participants and procedures
process included a variety of sources such as large and
Transgender participants small businesses, public service organizations, commu-
The sample consisted of all individuals who self-iden- nity centers, and recreational groups. The majority of
tify as transgender and participated in an assessment participants were recruited from urban/suburban loca-
at a national transgender health service in Notting- tions, although rural/semi-rural people were also rep-
ham, UK during a 3-year period between November resented. As per the transgender group, participants
2012 and October 2015. For the first aim of the study were invited to complete the Hospital Anxiety and
only individuals not on treatment with cross-sex hor- Depression Scale (Zigmond & Snaith, 1983) and place
mones (non-CHT) before assessment was be selected, them in a sealed envelope. The questionnaires were
in order to have a homogeneous group. filled out anonymously. The combined refusal/nonre-
Following assessment, the transgender person is turn rates ranged from approximately 17% to 21%.
considered for entry into the treatment program. Ethical approval was obtained from the Psychology
Treatment, including CHT and GAS is free at the Ethics Committee of the University of Aberdeen,
point of access in the National Health Service Scotland.
(NHS) in the United Kingdom for all citizens.
Patients will usually start CHT, following informed
Main outcome measures
consent, if there are no physical contraindications.
Chest reconstructive surgery is generally available The Hospital Anxiety and Depression Scale (HADS)
to trans men after being on testosterone treatment (Zigmond & Snaith, 1983) is a 14-item self-report
for a minimum of 6 months. Genital reconstructive screening scale that was originally developed to indi-
surgeries are generally available to transgender peo- cate the possible presence of anxiety and depression
ple after being in the treatment program for a min- states in the setting of a medical nonpsychiatric outpa-
imum of 12 months. We acknowledge that not all tient clinic. HADS consists of two subscales, HAD-
transgender people wish to take cross-sex hor- Anxiety (HAD-A) and HAD-Depression (HAD-D).
mones or undergo gender-confirming surgeries; a For this study, only the subscale of anxiety will be used.
growing number of transgender people express a This subscale has seven items, rated on a 4-point Likert
wish for partial treatment (Beek, Kreukels, Cohen- scale (with options as much as I always do (0); not quite
Kettenis, & Steensma, 2015). Once transgender so much (1); definitely not so much (2); and not at all
people have undergone their desired treatment, fol- (3)), indicating symptoms of anxiety during the pre-
low-up care can be organized at the service, if they ceding week. A score of 0 to 7 on either scale was
wish (Wylie et al., 2014). regarded as being in the normal range (no symptoms);
Prior to the clinical assessment every patient was a score of 8 to 10 is suggestive of the presence of an anx-
invited to participate in the study and, if agreeing to iety disorder (possible symptoms); and a score of 11 or
participate, to complete a battery of questionnaires. higher indicates the probable presence of an anxiety
The study received ethical approval from the NHS disorder (symptoms) of the respective state. Maximum
Ethics Committee and from the Research and Devel- subscales scores are 21 for anxiety. The HADS was
opment Department from Nottinghamshire Health- found to perform well in assessing the symptom sever-
care NHS Foundation Trust in line with Health ity and caseness of anxiety disorders in both somatic,
Research Authority guidance (HRA, 2013). psychiatric, and primary care patients and in the
4 W. P. BOUMAN ET AL.

general population (Bjelland, Dahl, & Neckelmann, (Boza & Perry, 2014; Davey et al., 2014, 2016). In this
2002), and it has been previously used with transgender study the Cronbach’s alpha was 0.89 for the total scale.
individuals (Bouman et al., 2016a; G omez-Gil et al., The Inventory of Interpersonal Problems (IIP-32)
2012). A number of researchers have explored HADS (Barkham, Hardy, & Startup, 1996) measures interper-
data to establish the cut-off points for caseness of anxi- sonal difficulties. It consists of 32 items to be rated on
ety. Bjelland et al. (2002) through a systematic review a 5-point Likert scale ranging from 0 (not at all) to 4
of a large number of studies identified a cut-off point of (extremely). There are eight subscales of interpersonal
8/21 for anxiety. For anxiety (HADS-A) this gave a problems: hard to be assertive, hard to be sociable,
specificity of 0.78 and a sensitivity of 0.9. In this study, hard to be supportive, hard to be involved, too depen-
the Cronbach’s alpha was 0.68 for the anxiety scale. dent, too caring, too aggressive, and too open. A total
The Rosenberg Self-Esteem Scale (RSE) (Rosen- mean score provides a global measure of interpersonal
berg, 1965) is a self-report measure of global self- distress. Higher subscale scores indicate greater inter-
esteem. Items are rated on a 4-point rating scale rang- personal difficulties. The IIP-32 is a shortened version
ing from 0 (strongly disagree) to 3 (strongly agree). Its of the original IIP, yet the psychometric properties are
total score is calculated by summing the item scores retained; a confirmatory factor analysis demonstrated
with higher scores indicating higher self-esteem. The high reliability with alpha coefficients of 0.70 to 0.88
RSE has been empirically validated and administered (Barkham et al., 1996). The IIP-32 has been used suc-
previously to transgender individuals (Arcelus et al., cessfully in both nonclinical (Berry, Wearden, Barrow-
2016; Vocks, Stahn, Loenser, & Legenbauer, 2009). In clough, & Liversidge, 2006) and clinical samples
this study the Cronbach’s alpha was 0.91. (Bouman et al., 2016b; Davey et al., 2015). In this
The Experiences of Transgender Phobia Scale study the Cronbach’s alpha was 0.87 for the total scale.
(Lombardi et al., 2001) assesses experiences of dis-
crimination or victimization on the basis of gender
Data analysis
identity or gender presentation. The questionnaire
was based on the Transgender Violence Study and All quantitative data analyses were performed by
measured people’s lifetime experiences of violence and means of SPSS 22 (IBM, 2013). First, descriptive statis-
harassment and experiences of any form of economic tics were applied. For the first aim, only transgender
discrimination as a result of being transgender (e.g., people will be included in order to have a homogenous
verbal abuse, physical abuse, fired from a job, prob- group. As per the authors’ advice, based on the HADS,
lems getting a job, and problems getting health or three categories will be developed: (1) people with no
medical services due to gender identity or presenta- anxiety disorder, (2) people with symptoms suggesting
tion). All five items are rated on a 4-point Likert scale of a possible anxiety disorder and, (3) people with
ranging from 0 (never) to 3 (several times). This scale symptoms suggesting a probable anxiety disorder. We
has been previously used with transgender individuals used the chi-square test statistic to calculate the associ-
(Arcelus et al., 2016; Bouman et al., 2016a; Bouman, ation between the three levels of anxiety symptomatol-
Davey, Meyer, Witcomb, & Arcelus, 2016b; Claes et ogy and the participant status (transgender and
al., 2015). In this study the Cronbach’s alpha was 0.59. controls) for the total group and for males/females
The Multidimensional Scale of Perceived Social separately. For the second aim, the prediction of the
Support (MSPSS) (Zimet, Powels, Farley, Werkman, presence/absence of an anxiety disorder—based on
& Berkoff, 1990) is a 12-item, self-report scale self-esteem, social support, interpersonal functioning,
designed to tap social support from family, friends, and victimization—and the use of CHT in transgender
and significant others. Items are rated on a 7-point people controlled for gender and age, we performed a
Likert scale ranging from 1 (very strongly agree) to 7 hierarchical regression analysis, with the presence/
(very strongly disagree). The instrument includes three absence of the anxiety disorder as a dependent vari-
subscales to address these three types of support: fam- able (dummy), age and gender (step 1) as control vari-
ily, friends, significant others. The mean total and sub- ables, and the other variables (step 2) as predictors.
scale scores range from 1 to 7, and a higher score For the third aim, the association between the pres-
indicates greater perceived social support. This scale ence/absence of an anxiety disorder and the use/non-
has recently been used in transgender populations use of CHT, we calculated the chi square test statistic
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 5

for the total group and for males/females separately. Probable Anxiety Disorder" compared to the control
The level of significance used was p < 0.05. group. This difference was statistically significant
[x2(2) D 148.997, p < .001]. When comparing trans
Results with cis men [x2(2) D 128,521, p < .001] and trans
with cis women [x2(2) D 21,443, p < .001], the differ-
Sociodemographic characteristics of the whole ence was still statistically significant.
sample
During the recruitment period of 3 years, 913 individ-
uals who fulfilled the inclusion criteria agreed to par- Predictors of anxiety disorders (probable and
ticipate. Twenty-five individuals (2.6%) did not agree, possible) among the whole transgender population
which gives a response rate of 97.4%. The age range of In order to analyze the predictors of anxiety in the
the participants was 15 to 79 years, with a mean age of transgender population, the whole group of 913 trans-
30.4 years (SD D 13.9); 582 (63.7%) patients identified gender people (excluding the 14 people without infor-
themselves as trans females (assigned male at birth) mation regarding CHT) were included (giving a total
and 331 (36.3%) as trans males (assigned female at of 899 individuals). Those in the category of probable
birth). Of the total sample of 913 transgender people, and possible anxiety symptoms were grouped together
640 (70.1%) were not on cross-sex hormone treat- into one category (anxiety disorder). A linear hierar-
ment, 259 (28.4%) were on CHT, while for 14 patients chical regression analysis with the presence or absence
(1.5%) this information was not available and they of anxiety disorder as dependent variable; age and
were removed for further analyses. gender as control variables; and self-esteem, social
support, interpersonal functioning; and victimization
Comparative analyses between transgender people and the presence and absence of CHT as independent
not on CHT and controls. variables was performed. The results showed that low
self-esteem and interpersonal problems were the only
For the first aim of the study only people not on CHT
significant predictors for a transgender person attend-
were selected (n D 640). Of the 640 patients in the
ing transgender health services to suffer from a possi-
non-CHT group, the age range was 16 to 79 years
ble and probable anxiety disorder. Interpersonal
with a mean age of 28.6 years (SD D 12.8); 393
functioning was a stronger predictor (See Table 2).
(61.4%) patients identified as trans females (assigned
male at birth) and 247 (38.6%) were trans males
(assigned female at birth). This group was matched by
Comparison between people on CHT and those not
age and experienced gender with the control group.
on CHT
Of the 640 patients in the non-CHT group, 48 (7.5%)
could not be matched due to insufficient numbers for Analyses comparing transgender people on CHT with
that age in the control data. This group consisted of those not on CHT found a statistically significant dif-
19 trans females and 28 trans males aged 17 and ference between both groups with more transgender
18 years with an average age of 17.3 years (SD D people using CHT in the category of no anxiety disor-
0.48). The remaining sample of 592 non-CHT patients der compared to those on not on CHT [x2(1) D 20,266,
were block matched with the control population data- p < .001]. The latter group is more prevalent in the cat-
base. This meant that for the first aim, a total of 1,184 egory anxiety disorder (see Table 3.). As the use of
participants were selected—592 in each group. CHT was more prevalent among trans females and
Out of the 592 transgender and cisgender partici- anxiety symptoms were more prevalent among trans
pants, 218 (36.8%) were trans and cis females and 374 men, the same analyses were performed according to
(63.2%) were trans and cis males, respectively. As gender. The new analyses showed that for trans
Table 1 shows, control group individuals were signifi- females, being on CHT was associated with less anxiety
cantly more prevalent in the category of "No Anxiety disorder as there were more trans females not on CHT
Disorder" compared to the transgender group, in the category of anxiety disorders compared to trans
whereas the transgender people were significantly females on CHT [x2(1) D 21,802, p < .001]. This was
more prevalent in the categories "Possible and not the case for trans males [x2(1) D 1,379, p < .240].
 6
W. P. BOUMAN ET AL.

Table 1. Comparison between the number of transgender (TG) people (men, women, and total) and cisgender controls regarding the existence or not of anxiety disorders (n D 1184).
Both genders Trans males Trans females
(n D 1184) (n D 436) (n D 748)

TG Controls TG Controls TG Controls

No anxiety (n D 592) (n D 592) (n D 218) (n D 218) (n D 374) (n D 374)
disorder n (%) 185 (31.2) 388 (65.5) 72 (33.0) 120 (55.0) 113 (30.2) 268 (71.6)

Anxiety Possible 407 (68.8) 194 (32.8) 204 (34.5) 126 (21.3) 146 (67.0) 67 (30.7) 98 (45.0) 58 (26.6) 261 (69.8) 126 (33.7) 106 (28.4) 68 (18.2)
disorders n (%) n (%)
Probable 213 (36.0) 78 (13.2) 78 (36.3) 40 (18.4) 133 (36.1) 38 (10.2)
n (%)

p < .05.
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 7

Table 2. Predictive role of age, gender, self-esteem, social support, interpersonal function, and victimization in transgender people with
possible and probable anxiety disorder (as one category) compared to transgender people with no anxiety disorder.
Unstandardized coefficients Standardized coefficients

Model B Std. Error Beta t p

1 (Constant) .824 .076 10.780 .000

Age –.005 .001 –.143 –3.830 .000
Assigned gender –.028 .037 –.028 –.751 .453
2 (Constant) .634 .107 5,911 .000
Age .001 .001 .028 .812 .417
Assigned gender .008 .031 .008 .239 .811
CHT before assessment –.001 .013 –.001 –.043 .966
Global score MSPSS –.002 .001 –.056 –1.754 .080
Total RSE –.019 .003 –.259 –6.404 .000
Global IIP score .256 .028 .348 9.243 .000
Total transphobia .006 .006 .030 1.002 .317
a
Dependent variable: HADS score; p < 0.05.

Discussion 2011). Studies looking into why anxiety symptoms are

more prevalent among individuals whose gender is
Anxiety disorders are the most common mental disor- assigned female at birth suggest that differences in
ders, with a reported 12-month prevalence of 18.1% neurobiological make-up may account for these differ-
and a lifetime prevalence of 28.8% (Kessler et al., ences. The brain system involved in the fight-or-flight
2005a; Kessler et al., 2005b). Moreover, women are response is activated more readily in female-assigned-
significantly more likely than men to develop an anxi- at-birth individuals and stays activated longer than
ety disorder throughout the lifespan (McLean et al., male-assigned-at-birth individuals, partly as a result
2011). Owing to their high prevalence, combined with of the action of estrogen and progesterone. The neuro-
an often early onset and chronic course, anxiety disor- transmitter serotonin may also play a role in respon-
ders are the second-most-important cause of disability siveness to stress and anxiety. Some evidence suggests
worldwide within the group of mental and behavioral that the brain of individuals whose sex is assigned
disorders (Whiteford et al., 2013; De Vries, De Jonge, female at birth does not process serotonin as quickly
Van den Heuvel, Turner, & Roest, 2016). This study as individuals whose sex is assigned male at birth.
found high rates of possible (32.8%) and probable Recent research has also found that female-assigned-
(36.0%) current anxiety disorder in untreated trans- at-birth individuals are more sensitive to low levels of
gender people attending a transgender health service. corticotropin-releasing factor (CRF)—a hormone that
Compared with a cisgender matched control group organizes stress responses in mammals—making
from the general population, transgender people had them twice as vulnerable as their male-assigned-at-
an almost threefold increased risk of probable anxiety birth counterparts to stress-related disorders (Ban-
disorder. Trans males showed higher rates of possible gasser, Wiersielis, & Khantsis, 2016).
and probable anxiety disorder (71.1%) than trans This study found low self-esteem and interpersonal
females (59.8%), which is in keeping with the litera- functioning to be predictors of anxiety disorder, which
ture on gender differences in anxiety disorders, if the highlights the importance of psychological intervention
pattern of birth gender is followed (McLean et al., and support in this vulnerable group. Psychological

Table 3. Differences in anxiety symptomatology based on the HADS in transgender people on cross-sex hormone treatment (CHT) and
those who are not on treatment (nD 899).
Transgender people not on CHT N (%) Transgender people on CHT N (%)

All (n D 640) Trans female (n D 393) Trans male (n D 247) All (n D 259) Trans female (n D 179) Trans male (n D 80)
   
No anxiety disorder 202 (31.5) 118 (30.0) 84 (34.0) 123 (47.5) 90 (50.3) 33 (41.2)
(Score 0–7)    
Possible or probable anxiety 438 (68.5) 275 (70.0) 163 (66.0) 136 (52.5) 89 (49.7) 47 (58.8)
disorder (Score  8)

p < 0.05.
8 W. P. BOUMAN ET AL.

treatment aiming at improving self-esteem and interper- may not be generalizable to other transgender people
sonal functioning may help transgender individuals at who do not access clinical services or to other coun-
risk of developing anxiety disorder when going through tries with different health care systems. Second, the
the transitional process. Various psychological treat- research makes use of self-reported questionnaires,
ments have proven efficacious in increasing self-esteem and although most are adequately validated and have
(Morton, Roach, Reid, & Stewart, 2012; Fennel, 2006; been used in transgender populations, future research
Rigby & Waite, 2007). Similarly, interpersonal psycho- could use structured clinical interviews to differentiate
therapy (IPT) has been found efficacious in reducing the clinical group from those with and without anxiety
interpersonal problems. As IPT has been successfully disorder and other psychiatric morbidity. Further-
used in various populations (e.g., Arcelus, Whight, & more, a limitation of the study is the cross-sectional
Haslam, 2011; Hara, Stuart, Gorman, & Wenzel, 2000; nature of the data. From the current data, it is not pos-
Mufson, Weissman, Moreau, & Garfinkel, 2013), it could sible to determine whether the psychological benefits
be adapted for use within the transgender population associated with the use of CHT predate or are a conse-
(Budge, 2013). For those transgender patients who meet quence of disclosure of experienced gender and/or
a diagnosis of anxiety disorder, current treatment social gender role transition. It also may be that those
approaches apply, including consideration of pharmaco- with better self-esteem and less psychopathology feel
therapy and/or psychological treatment (Baldwin et al., more confident to commence treatment without med-
2014; Iacoviello & Charney, 2015). ical advice. They may use the support and advice of
Further findings confirmed the benefits of cross-sex their friends who also may be taking CHT. The lack of
hormone treatment, particularly for trans women on information regarding the gender identity of the con-
CHT, as they were significantly more prevalent in the trol group used makes it impossible to generalize the
category "No Anxiety Disorder" compared to those results to the transgender population, as some of peo-
who do not use cross-sex hormones. That these findings ple in the control group may also identify as transgen-
do not apply to trans men is surprising, and certainly do der. This information was not asked, although, given
not reflect our clinical experience. One explanation may the low prevalence the impact on the final results is
be that the higher risk of developing anxiety disorder likely to be negligible (Arcelus et al., 2015). Many
for people whose sex was assigned female birth offsets studies in the field of transgender health have included
the positive psychological benefits of CHT in trans people fulfilling a diagnosis as per the ICD or DSM
men. This specific area needs further study. The find- (e.g., Colizzi et al., 2013; de Vries et al., 2011; Gomez-
ings confirm existing research (Bouman et al., 2016; Gil et al., 2012; Heylens et al., 2014a) as well as relying
Colizzi et al., 2014; De Vries et al., 2014; G
omez-Gil et on self-identification regarding one’s gender (e.g.,
al., 2012; Heylens et al., 2014b) and add further weight Bockting et al., 2013; Davis & Colton Meier, 2014;
to the rationale of early treatment for gender dysphoria. Reisner, Katz-Wise, Gordon, Corliss, & Bryn Austin,
In many countries, long waiting lists and lack of clinical 2016; Warren, Bryant Smalley, & Barefoot, 2016).
services for transgender people combined with overly This study has not used a diagnosis to classify people
prescriptive pathways to access CHT in standards of but selected a population of people who self-identify
care (Coleman et al., 2012; Wylie et al., 2014) continue as transgender and access transgender health services
to be significant barriers to treatment for transgender for treatment. It can be argued that the population
people. Moreover, these barriers to access treatment are selected in this study may be slightly different from
likely to further increase the rate of anxiety disorders; the one fulfilling diagnostic criteria, although this is
also, they tend to lead to self-prescribing via the Inter- not our clinical impression, but we do want to
net without medical supervision (Mepham, Bouman, acknowledge this difference. A final note on the gener-
Arcelus, Hayter, & Wylie, 2014). alizability of the findings is that there are particular-
There are aspects of the study that warrant atten- ities with regard to medical treatment and legislation
tion in relation to limitation of the results. First, the for transgender people in the United Kingdom. For
study is limited by selecting a specific population of example, some aspects of gender reassignment treat-
treatment-seeking individuals and doing so in a coun- ment (e.g., CHT and/or GCS) are available through
try in which the waiting list for a first appointment at the NHS free at the point of access, and the Gender
a transgender health service is long. Hence, the results Recognition Act 2004 provides legal recognition of a
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 9

trans individual’s experienced gender. In addition, the interpersonal psychotherapy. In P. Hay (Ed.), New insights
Sex Discrimination (Gender Reassignment) Regula- into the prevention and treatment of bulimia nervosa (pp.
tions Act 1999 and its amendment in 2008 deemed it 3–12). Rijeka, Croatia: InTech.
Baldwin, D. S., Anderson, I. M., Nutt, D. J., Allgulander, C., Ban-
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Bangasser, D. A., Wiersielis, K. R., & Khantsis, S. (2016). Sex
countries (Davey et al., 2015).
differences in the locus coeruleus-norepinephrine system
In spite of the above limitations the strength of the and its regulation by stress. Brain Research, 1641, 177–188.
paper is the large group of transgender and control Barkham, M., Hardy, G. E., & Startup, M. (1996). The IIP-32:
group involved, making this one of the largest studies A short version of the Inventory of Interpersonal Problems.
in the field. The study is also strengthened by the British Journal of Clinical Psychology, 35, 21–35.
matching of groups (transgender and controls and Beek, T., Kreukels, B. P. C., Cohen-Kettenis, P. T., & Steensma,
T. D. (2015). Partial gender request and underlying motives
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has been criticized previously (Dhejne et al., 2016). Bergero-Miguel, T., Garcıa-Encinas, M. A., Villena-Jimena, A.,
Notwithstanding the aforementioned limitations, Perez-Costillas, L., Sanchez-Alvarez, N., de Diego-Otero,
this study clearly shows that treatment-seeking trans- Y., & Guzman-Parra, J. (2016). Gender dysphoria and social
gender individuals have a high prevalence rate of pos- anxiety: An exploratory study in Spain. Journal of Sexual
Medicine, 13, 1270–1278.
sible and probable anxiety disorder compared to the
Berry, K., Wearden, A., Barrowclough, C., & Liversidge, T.
general population. Having an experienced male gen- (2006). Attachment styles, interpersonal relationships and
der, low self esteem, interpersonal problems and lack psychotic phenomena in a non-clinical student sample. Per-
of cross-sex hormone treatment are specifically associ- sonality and Individual Differences, 41, 707–718.
ated with an increased likelihood of coexisting anxiety Bjelland, I., Dahl, A. A., & Neckelmann, T. T. (2002). The
disorder in transgender people, having low self esteem validity of the Hospital Anxiety and Depression Scale. An
updated literature review. Journal of Psychosomatic
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Research, 52, 69–77.
for anxiety. Mental health services should take heed of Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham-
these findings to improve outcomes in this vulnerable ilton, A., & Coleman, E. (2013). Stigma, mental health, and
group of individuals. resilience in an online sample of the US transgender popula-
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Declaration of interest
of the transgender coming-out process. Chapter 9. In R. Ett-
The authors declare that they have no conflicts of interest con-
ner, S. Monstrey, & E. Coleman (Eds.). Principles of trans-
cerning this article.
gender medicine and surgery. New York, NY: Routledge.
Bouman, W. P., Claes, L., Marshall, E., Pinner, G. T., Long-
ORCID worth, J., Maddox, V., … Arcelus, J. (2016a). Socio-demo-
Jon Arcelus http://orcid.org/0000-0002-3805-0180 graphic variables, clinical features and the role of pre-
assessment cross-sex hormones in older trans people. Jour-
nal of Sexual Medicine, 13(4), 711–719.
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