Tag Archives: anxiety

Review of Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.


The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.


The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.


Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?


The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*


Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.


*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.

Sex Dimorphism of the Brain in Male-to-Female Transsexuals – Review

This study found that trans women (born male) had brains like men’s, at least in terms of gray and white matter volumes and hemispheric asymmetry.

In a few areas, trans women’s brains were different from both men’s and women’s brains.

The authors suggest that the differences they found between trans women and cis people’s brains are related to body perception.

They conclude:

“The present data do not support the notion that brains of MtF-TR are feminized. The observed changes in MtF-TR bring attention to the networks inferred in processing of body perception.”

The study only looked at trans women who were attracted to women. This is both a strength and a limitation of the study.

It is a strength because it avoids confusion between gender identity and sexual orientation. Many recent studies have compared trans women attracted to men to men attracted to women; if you find a difference between the two groups, you can’t be sure if it is due to sexual orientation or gender identity.

This study, however, compared trans women attracted to women with men attracted to women and women attracted to men.

This is also a limitation because it is extremely unrepresentative of trans women. About half of trans women are attracted to men, much more than in the general population. If we want to understand how gender dysphoria works, we need to look at both groups of trans women.

A study looking at just trans women attracted to women was necessary, but clearly we need some follow-up research. Is this result true for trans women who are attracted to men? How do these results compare to cis gay men’s brains?

You can stop here if you want. You now know the main result of the study.

On to the specifics of the study. What exactly did they find?

Ways trans women’s brains were like men’s brains

1. Total brain tissue volume was smaller in heterosexual women (HeW) than in heterosexual men (HeM)  and gyenephillic male to female transsexuals (MtF-TR).*

(Gyenephillic=attracted to women.)

2. Total intracranial volume was smaller in HeW than in HeM or MtF-TR. There was no difference between the groups in total white matter volume or total gray matter volume when you took into account the total intracranial volume.

3. HeM had a larger gray matter volume than HeW in the lingual gyrus, the cerebellum, right putamen, and left amygdala and perirhinal cortex. HeW had larger gray matter and white matter volumes in the precentral gyrus.

None of these differences were reproduced when comparing HeM to MtF-TR.

4. HeW had larger hippocampi compared to both HeM and MtF-TR, mostly due to the left hippocampus. There was no difference between HeM and MtF-TR.

5. HeM and MtF-TR had rightward assymetries in the brain; HeW did not. Specifically:

a. the volume of the right hemisphere was larger than the left for HeM and MtF-TR, but not for HeW;

b. the volume of the thalamus was significantly larger in the right hemisphere for HeM and MtF-TR, but not for HeW – however, there was no significant differences in the groups’ assymetry indices (volume of right side/volume of left side).

c. the volume of the hippocampus was significantly larger in the right hemisphere for HeM, but not for HeW. The volume was also larger for MtF-TR, but this was not statistically significant – although the p-value was 0.065, so it was close. However, the differences in assymetry indices between MtF-TR and HeW and between HeM and HeW were significant.

Ways trans women’s brains were different from cis people’s brains

1. MtF-TR had larger gray matter volumes than either HeM or HeW in the “right temporo-parietal junction (around the angular gyrus and in the posterior portion of the superior temporal gyrus)**, and right inferior frontal and insular cortex.”

2. MtF-TR had a smaller gray matter volume than either HeM or HeW in the thalamus.

3. MtF-TR had smaller thalamuses and putamens than either HeM or HeW; this was a measurement of the regional structural volume. There was no difference between HeM or HeW.

Areas where they found no differences between the groups

1. There were no group differences in the caudate volume.

2. There was no assymtery in the caudate or putamen.

What does all this mean?

First, it does look like the authors are right; the trans women’s brains were more like men’s than women’s. It is possible that trans women’s brains are like women’s brains in some other way than the ones the authors looked at. Nevertheless, the similarities to men’s brains found in this study are fairly large.

What is perhaps, more interesting, is the ways that the trans women’s brains were different from cis people’s brains, whether they were male or female.

The authors of the study point out that these are new findings and they need to be confirmed with larger studies. “Any interpretation must, therefore, proceed cautiously and can at this point only be highly speculative.”

The authors go on to suggest that their findings might be related to own body perception. As they point out, one of the main symptoms of gender dysphoria is discomfort with your own body. Some studies suggest that the areas of the brain where trans women were different from cis men and women could be part of a network involved in own body perception.

Of course, as in other studies, the parts of the brain involved in this study have multiple functions. For example, the angular gyrus is also involved in language, math, and memory retrieval. So we can’t be sure exactly what it means that trans women have a larger volume of gray matter in those areas.

On the other hand, people with gender dysphoria don’t have problems with language and math, they have problems with dysphoria about their bodies.

More surprisingly, the authors of this study suggest that people with gender dysphoria may have changed their brains by constantly thinking about their bodies. This is possible, but it seems more likely to me that the problem starts with something in the brain causing people to feel uncomfortable with their bodies.

Here is the author’s argument from their conclusion:

“There is no evidence that this feeling [gender dysphoria] is caused by a general sensory deficit in transsexual persons…Several studies propose that own body perception involves networks in the temporo-parietal, inferior parietal cortex, the inferior frontal, and insular cortex, and their connections with the putamen and thalamus. Thus, theoretically, the experience of dissociation of the self from the body may be a result of failure to integrate complex somatosensory and memory processes executed by these networks.

Such disintegration accords with the present findings and could, perhaps, explain recent observation of poorer parietal cortex activation during a spatial orientation task in MtF-TR compared with male controls.

However, it is difficult to explain how such disintergration can be linked to a dysphoria restricted to the own body’s sex characteristics.

Moreover, even if a link exists, it is uncertain whether the here observed morphometric features in transsexual patients underpin their gender identity or are a consequence of being transsexual.

One highly speculative thought is that the enlargement of the GM volume in the insular and inferior frontal cortex and the superior temporal-angular gyrus could derive from a constant rumination about the own body. Brain tissue enlargement has been detected in response to training, and GM enlargement of the insular cortex has been reported in response to meditation, which involves mental focusing on the own body.”

The authors also point out that it might be that something else is causing both gender dysphoria and changes in neuroanatomy.

They stress that we can’t directly connect changes in gray matter volume to effects on the person.

They point out that they did not look at the hypothalamus, so their findings do not contradict earlier studies of it.

Finally, they call for more research, including research which compares trans women attracted to men to trans women attracted to women, and trans women attracted to men to cis gay men. (Yay!)

“Furthermore, they [the results] were generated exclusively from investigations of nonhomosexual, gynephillic MtF-TR. The issue of possible cerebral difference between gynephillic and androphillic (homosexual) MtF-TR and also between androphillic MtF-TR and homosexual healthy men is of special interest and needs to be addressed separately in future studies. Additional studies of the relationship between brain structure and function in transsexual persons and also extending the material to female to male transsexuals are necessary to more precisely interpret the present observations.”

The bottom line: we need more studies confirming these results. Is there a link between gender dysphoria and the network involved in own body perception? If so, which is the cause and which is the effect? Do these results hold true for trans women who are attracted to men? What about trans men?

There were two results the study did not discuss. It may not mean anything, but I think it is worth mentioning.

1. The volume of the amygdala was larger in HeM than HeF; this fits with other studies of sex differences in the brain. For MtF-TR, their amygdalas seems to have been neither bigger nor smaller than males or females. (Table 3)

2. The subcallosum (BA 24, 32) was larger in HeF than HeM. This fits with a study the authors cite showing that women have larger anterior cingulate gyri – the anterior cingulate cortex includes Brodmann Areas 24 and 32. This area seems to have been neither larger nor smaller in MtF-TR.

According to the authors: “Although sex differences have been described also in the amygdala and cingulate gyrus, these structures were not included in the analysis because the identification of anatomical landmarks in these regions is less reliable, especially when using a 1.5-T scanner.”

In other words, they think there could have been an error in the results. Either there was no sex difference in those areas, or they failed to detect differences between trans and cis women in those areas.

Another possibility is that trans women and cis women were not different in those areas because trans women’s volumes were intermediate between cis men’s and cis women’s.

If this is so, there are many possible explanations. It might have something to do with sex hormones, although it is hard to see why trans women’s brains would have developed like cis men’s in most parts of the brain if they weren’t exposed to sex hormones. You would have to assume that there was something different about how their amygdala and cingulate gyrus responded to sex hormones.

Another possibility is that trans women’s amygdalas were as large as men’s amygdalas, but something made them shrink.

Studies have linked a smaller amygdala to obsessive-compulsive disorder (OCD), anxiety, PTSD, sociopathy, and early life stress (abuse, neglect, or poverty). [Click through to see the studies.]

Trans people have higher rates of anxiety than other groups, but this study excluded people with any psychiatric disorders.

Trans people also suffer higher rates of abuse and trauma than most people which might have affected their amygdalas.

A final, hypothetical possibility might be that gender dysphoria is in some way related to OCD.

In the case of the cingulate gyrus, we would have to assume that something happened to trans women’s brains to make the volume of their cingulate gyrus increase to be intermediate between cis women and cis men. This is harder to understand, since OCD, anorexia, and body dysmorphic disorder are all correlated with decreases in the size of the anterior cingulate cortex.

However, there is one study suggesting that a large right anterior cingulate “is related to a temperamental disposition to fear and anticipatory worry.” No doubt the experience of being transgender in our society causes people to worry and feel fear; perhaps this changes the brain. Alternatively, it might be that a tendency to worry is somehow linked to developing gender dysphoria.

Original Study:

Sex Dimorphism of the Brain in Male-to-Female Transsexuals by Savic I, Arver S. in Cereb Cortex. 2011 Nov;21(11):2525-33.

A few fun facts:

You can induce out-of-body experiences by stimulating either the temporo-parietal junction or the angular gyrus. (Read more here and here).

The right temporo-parietal junction is also involved in thinking about thoughts. It, or an area close to it, is involved in directing your attention. (Read more here and here.)

The superior temporal gyrus is involved in recognizing your own face, identifying emotions in other people’s faces, and social cognition.

Information about the self may be processed in the right hemisphere; however, not everyone agrees on this theory. (Read more here.)

Increased volume in the left inferior frontal gyrus and right amygdala are associated with worse symptoms in body dysmorphic disorder. The trans women in this study had increased volumes in the right inferior frontal gyrus only. This does, however, suggest that these areas of the brain are important to perceptions of the body. (Read more here.)

*I am using the language of the study now.

** The original text refers to the superior temporal gurus. A cool idea, but probably a typo.

Psychiatric comorbidity among patients with gender identity disorder – Partial Review

This study looked at the patients at a Japanese clinic for gender identity disorder to see if they had any other mental health issues. They did not find a high rate of autism spectrum disorders (ASDs).

This is not a review of the full study, just the information related to ASD.

Out of 579 patients that they treated, only 4 were diagnosed with Asperger’s disorder and there were no other cases of autism spectrum disorders.

In other words, less than 1% of this group had an ASD.

All of the patients with Asperger’s were born male.

This data is worth noting because it is so different from results in other countries. Are patients with autism not referred to the GID clinic in Japan? Is autism being diagnosed the same way in the different studies? Are adult patients less likely to have ASD than children and teenagers with gender dysphoria?

This data also highlights the fact the gender dysphoria and autism spectrum disorders are connected in males, not just females – in fact, in this case, they were connected only in males.

There is a theory that having an “extreme male brain” makes some girls with autism develop gender dysphoria. While that could still be true, it does not explain why males with autism would feel that they are females.

Instead of an “extreme male brain,” there might be some other mechanism that connects autism and gender dysphoria in both trans women (born male) and trans men (born female).

Another interesting aspect of the data was that they diagnosed 96% of the patients they saw with GID. Of the 24 patients who were not diagnosed with GID, half had severe psychological disorders like schizophrenia. Eight were excluded for homosexuality and four were excluded for transvestic fetishism.

I am not sure why they diagnosed such a high percentage of their patients with GID. Perhaps by the time people are referred to their clinic, they have been diagnosed by other doctors. It might also be somehow related to the definition of GID or the process of diagnosis.

I am assuming they excluded the gay patients because the patients discovered that they did not have GID and that the clinic is not excluding all gay patients. Most people with GID are attracted to people of their birth sex.

Other important results from the abstact:

“Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).”

The horrifying part has been bolded. I’m putting off talking about it until another day when I can deal with it.

I’ll just add that the authors suggested that “the harsh circumstances in which most GID patients have lived in Japan might influence the high rate of suicidal ideation or self mutilation in GID patients.”

Original Article:

Psychiatric comorbidity among patients with gender identity disorder by Masahiko Hoshiai MDYosuke Matsumoto MD, PhDToshiki Sato MD, PhDMasaru Ohnishi MD, PhDNobuyuki Okabe MDYuki Kishimoto MDSeishi Terada MD, PhD, and Shigetoshi Kuroda MD, PhD in Psychiatry and Clinical Neurosciences Volume 64, Issue 5, pages 514–519, October 2010.