Neural Correlates of Psychosis and Gender Dysphoria in an Adult Male

The risk of psychosis for transgender individuals: a Dutch national cohort study

BACKGROUND

The stressful minority position of transgender persons may result in a high risk of psychosis. Conflicting data suggest that the observed risk depends on setting of recruitment. We assessed the relative risk of non-affective psychotic disorder (NAPD) in a large, representative cohort of transgender persons.

METHODS

This cohort was composed using: data on legal sex change from the Dutch population registry and data on dispensing of cross-sex hormones (route 1), and a registry of insurance claims from mental health care including persons with a diagnosis of gender identity disorder (DSM-IV) or gender dysphoria (DSM-5) (route 2). They were matched by sex at birth, calendar year and country of birth to controls from the general population. Transgender persons (N = 5564) and controls (N = 27 820), aged 16-60 years at 1 January 2011, were followed until the first insurance claim for NAPD in 2011-2019.

RESULTS

The incidence rate ratio (IRR) of NAPD for transgender persons selected exclusively through route 1 (N = 3859, IRR = 2.00, 95%-CI 1.52-2.63) was increased, but significantly lower than the IRRs for those selected exclusively through route 2 (N = 694, IRR = 22.15, 95%-CI 13.91-35.28) and for those found by both routes (N = 1011, IRR = 5.17, 95%-CI 3.57-7.49; p value for differences in IRR < 0.001).

CONCLUSIONS

This study supports the social defeat-hypothesis of NAPD. The results also show the presence of a substantial number of transgender persons with severe psychiatric problems who have not (yet) taken steps to gender-affirmative care.

"Diagnosing" Gender? Categorizing Gender-Identity Variants in the Anthropocene

In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia-usually designed for one of the traditional sexes-typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.