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Transsexualism and personality: methodological and clinical studies on gender identity disorders
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
1994 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Patients suffering from transsexualism (TS) who apply for sex reassignment surgery (SRS) go through a complex evaluation process before being accepted for treatment. In general, the results from SRS are satisfying. However, further knowledge is needed to clearly delineate transsexualism from other related gender identity disorders (GID) and to improve the selection of candidates for SRS. Personality has for a long time been considered as the key concept for that purpose but systematic studies using reliable instruments are lacking. The present study aims at improving the assessment procedure, validating the concept of transsexualism and studying the outcome of SRS and important prognostic factors.

Two methodological studies deal with the development and validation of two self-report instruments based on DSM-III-R: SCID screen covering Axis II personality disorders/traits and Global Assessment of Functioning (GAF-scale, Axis V). SCID screen diagnoses of personality disorders (PD) were compared with diagnoses from independent structured interviews by means of the SCID-II. The overall kappa in identifying a PD was 0.78 varying from 0.34 to 0.81 for the specific PDs when cut-off was adjusted. When applied to a group of GID-patients SCID screen diagnoses agreed well with clinical diagnoses (kappa 0.77). Self-report of the GAF also proved to be a reliable (overall Pearson r=0.62) and useful method and the study lends further support to the validity of Axis V.

In three papers a group of 19 transsexuals was studied by means of a) SCID screen to examine their personality in a dimensional and traditional categorical way, b) the GAF-scale to study psychosocial functioning, c) Structural Analysis of Social Behavior (SASB) to examine self-image and d) Defense Mechanism Test (DMT) to analyze psychological defense structures from a psychodynamic perspective. Patients with atypical gender identity disorders (GIDAANT) and patients with borderline personality disorders as well as healthy subjects were used as contrast groups. Among the transsexuals 10 out of 19 had an additional axis I disorder and 37% had at least one PD, predominantly within cluster B. When analyzed dimensionally according to SCID screen, frequent subthreshold personality pathology was found and biological women fulfilled more axis II criteria than men. TS had less axis I and II pathology compared with GIDAANT and psychiatric patients. According to SASB, TS had a positive self-image with both self-control and spontaneous self and predominating self-love. They appeared significantly more healthy on self-image measures than GIDAANT patients. The DMT revealed a different pattern; TS patients were more disturbed in several areas than patients with borderline personality disorder. TS showed no ”emotional investment” and poorer reality orientation in contrast to both healthy controls and the borderline group but shared a similar pregenital pathology with the borderline patients.

Finally, five-year outcome was studied among the transsexuals from a multidimensional approach (e.g. work, interpersonal relations, partnership, subjective opinion) and related to index- measurements on DSM-III-R, SCID screen, GAF, SASB and DMT. Based on combined outcome variables, 68% of the subjects were judged to have improved and 16% had an unsatisfactory outcome. One single case regretted the sex change. SCID screen pathology and SASB disturbances emerged as significant predictors for negative outcome, as well as male biological sex and lack of partnership. It was concluded, that although outcome is in general very favorable, the instruments under investigation, in particular SCID screen and SASB, revealed valuable prognostic information and they are suggested to become part of the future routine assessment of candidates for SRS.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 1994. , 38 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 423
Keyword [en]
Transsexualism, Personality, GID, Sex reassignment, Outcome, SCID screen, GAF, SASB, DMT
National Category
URN: urn:nbn:se:umu:diva-100587ISBN: 91-7174-973-XOAI: diva2:793000
Public defence
1995-01-13, Rosa salen, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå universitet, Umeå, 10:00

Diss. (sammanfattning) Umeå : Umeå universitet, 1995, härtill 6 uppsatser.

Available from: 2015-03-16 Created: 2015-03-04 Last updated: 2015-04-08Bibliographically approved
List of papers
1. SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R.
Open this publication in new window or tab >>SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R.
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1994 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 90, no 2, 120-3 p.Article in journal (Refereed) Published
Abstract [en]

A modified version of the SCID Screen questionnaire covering 103 criteria by means of 124 questions was compared with SCID II interviews in 69 psychiatric patients. The correlation between the number of criteria fulfilled in the SCID II interviews or the questionnaires was 0.84. In the SCID interviews, 54% of the patients had a personality disorder. When the SCID Screen questionnaire was used, 73% had a personality disorder. When the cut-off level for diagnosis was adjusted, the frequency found by means of the SCID screen questionnaire or the interviews was roughly the same, 58% and 54%, respectively. The overall kappa for agreement between the SCID II interviews and questionnaire with adjusted cut-off was 0.78.

urn:nbn:se:umu:diva-43956 (URN)7976457 (PubMedID)
Available from: 2011-05-16 Created: 2011-05-16 Last updated: 2015-03-16
2. Axis V--Global Assessment of Functioning Scale. Evaluation of a self-report version.
Open this publication in new window or tab >>Axis V--Global Assessment of Functioning Scale. Evaluation of a self-report version.
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1994 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 90, no 5, 342-7 p.Article in journal (Refereed) Published
Abstract [en]

The present study examines a self-report version of the Global Assessment of Functioning Scale according to Axis V (GAF self-report). The sample (n = 73) was a psychiatric outpatient population from a catchment area clinic. Patients with psychotic and organic mental disorders were not included. The diagnostic distribution on Axis I was similar to the findings from previous studies. Axis II disorders were identified among 47%, of whom a majority also had a concomitant Axis I disorder. The mean GAF expert score was 66.5 (range: 48-86). High complexity and severity of disorders and a high number of fulfilled Axis II criteria were significantly associated with low GAF scores. Independent expert ratings on GAF were correlated with the GAF self-report overall at r = 0.62, varying from 0.45 to 0.91 between different diagnostic groups. In general, the patients scored themselves lower (mean: -4.4 units) than expert ratings. Patients with depressive symptoms from an adjustment disorder or mood disorder were most prone to underestimation. Women also tended to score themselves lower than experts did. Conclusively, the GAF self-report turned out to be a valid and reliable unidimensional instrument measuring psychological, social and occupational functioning. The GAF is easy to handle, and with a self-report version as a complement, Axis V could be more frequently used in future clinical practice and research.

urn:nbn:se:umu:diva-36455 (URN)7872038 (PubMedID)
Available from: 2010-09-30 Created: 2010-09-30 Last updated: 2015-03-16
3. Personality traits and disorders among transsexuals.
Open this publication in new window or tab >>Personality traits and disorders among transsexuals.
1993 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 88, no 5, 322-7 p.Article in journal (Refereed) Published
Abstract [en]

A group of transsexuals, 9 biological men and 10 women, was assessed according to clinical DSM-III-R diagnosis and a self-report instrument for Axis II diagnoses based on the Structured Clinical Interview for DSM-III-R (SCID screen). A control group of 133 individuals was assessed by the same instrument. Combined with a functional criterion according to the Global Assessment of Functioning, the SCID screen showed good agreement with clinical Axis II diagnoses. The overall proportion of Axis II criteria fulfilled, proportion of criteria fulfilled for every single personality disorder and number of personality disorders were calculated from the modified version of the SCID screen. Personality disorders, mainly within cluster B, were identified among 5 of 19 transsexuals, and a majority had multiple personality disorders. Among controls, no personality disorder was identified. Personality traits as measured by the SCID screen revealed significantly more subthreshold pathology among transsexuals than controls in 8 of 12 personality categories. The proportion of overall Axis II criteria fulfilled was 29% among transsexuals versus 17% among controls. Sex differences among transsexuals, the usefulness of the SCID screen and diagnostic problems in DSM-III-R with respect to gender identity disorders are discussed.

urn:nbn:se:umu:diva-36458 (URN)8296575 (PubMedID)
Available from: 2010-09-30 Created: 2010-09-30 Last updated: 2015-03-16
4. Self-image and personality traits in gender identity disorders: an empirical study.
Open this publication in new window or tab >>Self-image and personality traits in gender identity disorders: an empirical study.
1994 (English)In: Journal of sex & marital therapy, ISSN 0092-623X, E-ISSN 1521-0715, Vol. 20, no 4, 303-17 p.Article in journal (Refereed) Published
Abstract [en]

Self-image and personality traits, measured by SASB and SCID screen respectively, were compared between transsexuals, patients diagnosed as Gender Identity Disorders of Adolescence and Adulthood, Non-transsexual Type (GIDAANT), and normal controls. Transsexual and GIDAANT patients differed significantly in both their self-image and personality traits. While both the transsexuals' and controls' self-images were positive with self-love, the GIDAANT patients had a negative self-image. On the SCID screen, the GIDAANT group fulfilled 39.8% of all axis II criteria; transsexuals fulfilled 28.6% versus 17.1% for the control group. Mean GAF scores (axis V) were 62, 70, and 83, respectively. For all patients a more negative self-image was significantly related to lower social functioning according to GAF and to more personality pathology according to SCID screen. The prevalence of additional clinical axis I and II disorders was about twice as high among GIDAANT patients as among transsexuals. Although the two conditions are closely related, we found more differences than similarities in the studied aspects and a clear tendency that the GIDAANT patients had more psychopathology overall. Although the transsexuals also differed significantly in some aspects from the controls, they showed less personality pathology and they had a normal self-image. Negative self-image, high degree of fulfilled axis II criteria, and low GAF scores seem to be corresponding factors and in this study clearly differentiate transsexuals from GIDAANT patients.

urn:nbn:se:umu:diva-36475 (URN)7897678 (PubMedID)
Available from: 2010-09-30 Created: 2010-09-30 Last updated: 2015-03-16
5. Transsexualism--general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex.
Open this publication in new window or tab >>Transsexualism--general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex.
1996 (English)In: Archives of Sexual Behavior, ISSN 0004-0002, E-ISSN 1573-2800, Vol. 25, no 3, 303-16 p.Article in journal (Refereed) Published
Abstract [en]

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

urn:nbn:se:umu:diva-36447 (URN)8726553 (PubMedID)
Available from: 2010-09-30 Created: 2010-09-30 Last updated: 2015-03-16

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