GENDER IDENTITY DISORDER (GID) is characterized. Stress-coping strategies of patients with gender identity disorderpcn_

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1 Psychiatry and Clinical Neurosciences 2009; 63: doi: /j x Regular Article Stress-coping strategies of patients with gender identity disorderpcn_ Yosuke Matsumoto, MD, PhD, 1 Toshiki Sato, MD, PhD, 1 Masaru Ohnishi, MD, PhD, 2 Yuki Kishimoto, MD, 1 Seishi Terada, MD, PhD, 1 * and Shigetoshi Kuroda, MD, PhD, 1 1 Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences and 2 Health Service Center, Okayama University, Okayama, Japan Aims: Previous research has not addressed gender differences in coping strategies among patients with gender identity disorder (GID). Nor has the relationship of coping strategies to other demographic characteristics ever been clarified in GID. In this study, we tried to clarify the relationship between stress-coping strategies and demographic characteristics among patients with GID. Methods: The coping strategies of 344 patients with GID [227 female-to-male (FTM) and 117 male-tofemale (MTF)] were assessed using the Japanese version of the Ways of Coping Questionnaires, Lazarus Stress-coping Inventory. Results: Comparison of the stress-coping inventory between MTF and FTM GID patients revealed that FTM GID patients were significantly more reliant on positive reappraisal strategies in stressful situations than MTF GID patients (P = 0.007). Conclusions: The difference in the usage of positive reappraisal strategies between MTF and FTM type GID patients was not explained by other demographic characteristics, and we suppose that the gender difference in GID patients might influence the usage of positive reappraisal strategies. The ratio of FTM GID patients might be higher at our center because MTF GID patients can obtain vaginoplasty easily, whereas phalloplasty surgery for FTM GID patients is performed at only a few centers, including our clinic, in Japan. As a result, more FTM GID patients come to our clinic with a clear intention to undergo sexual rearrangement surgery, which might influence the gender difference in using positive reappraisal. Key words: female-to-male type, gender difference, gender identity disorder, male-to-female type, stress-coping. GENDER IDENTITY DISORDER (GID) is characterized by a strong and persistent identification with the opposite sex and discomfort with one s own sex. 1 Compared with many other psychiatric disorders, GID is rare, with an estimated worldwide lifetime prevalence of 0.001% 0.002% 2 or % %. 3 The incidence of GID patients *Correspondence: Seishi Terada, MD, PhD, Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Shikata-cho, Okayama , Japan. terada@cc.okayama-u.ac.jp Received 19 December 2008; revised 14 June 2009; accepted 1 July who requested sex reassignment therapy was reported to be 0.14/100,000/year in Sweden. 4 Thus, it has been difficult to establish demographic characteristics, and reports of large samples from countries outside of North America and Western Europe are extremely limited. 5 It is reported that children with GID are at high risk for developing psychiatric problems 6 and that the lifetime psychiatric comorbidity in GID patients is high. 7 For most GID patients, a strong and persistent identification with the opposite sex and discomfort with one s own sex is a life challenge that often creates distress and carries potential stigmatization. Therefore, it is important for GID patients to learn how to cope with this stressful situation. 715

2 716 Y. Matsumoto et al. Psychiatry and Clinical Neurosciences 2009; 63: Coping is defined as the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and the conflicts between them. 8 Such coping efforts serve two main functions (coping strategies): the management or alteration of the person environment relationship that is the source of stress (problem-focused coping) and regulation of stressful emotions (emotion-focused coping). 8 Folkman and Lazarus found eight scales of coping behaviors 9,10 and described the different coping scales. 10,11 Planful problem solving and confrontative coping are described as efforts to alter the situation and can therefore be characterized as problemfocused coping. Distancing, self-controlling, accepting responsibility, and escape/avoidance are described as ways of managing a stressful situation through cognitive and emotional efforts without changing the situation itself. These strategies are therefore characterized as predominantly emotionfocused coping. 10 The remaining scales (seeking social support and positive reappraisal) are more mixed in character and could be seen as either emotion-focused or problem-focused coping depending upon the situation. Despite the importance that is attributed to coping as a factor in psychological and somatic health outcomes, little is known about actual coping processes and the variables that influence them in patients with GID. In this study, we tried to clarify the relationship between stress-coping strategies and demographic characteristics among patients with GID. METHODS GID clinic The GID Clinic at Okayama University Hospital, the second oldest GID clinic in Japan, was established in Okayama in During the study period, the GID Clinic at Okayama University Hospital was the only special GID clinic in western Japan. It consists of four departments: psychiatry, urology, gynecology, and plastic and reconstructive surgery. The services at the GID Clinic include diagnosis, counseling, genetic testing, hormonal therapy, plastic surgery, and coordination of social services resources. All aspects of the present study were approved by the Ethical Committee of Okayama University Hospital. Subjects A total of 603 consecutive Japanese patients consulted the outpatient GID Clinic of Okayama University Hospital between 1 April 1997, and 31 October All patients were comprehensively evaluated independently by at least two senior psychiatrists with a special interest in this area, and 579 of 603 patients fulfilled the criteria for GID according to the DSM-IV. All 579 patients underwent a standard psychiatric evaluation to diagnose psychiatric comorbidities, such as schizophrenia or mood disorder, according to DSM-IV. Current psychiatric comorbidity was diagnosed in 84 patients, and 495 patients were without psychiatric comorbidity. To avoid the influence of current psychiatric comorbidity, only patients without psychiatric comorbidity were included in this study. GID patients complete a psychiatric test battery including stress-coping inventory (SCI) prior to treatment at our clinic. Of 495 GID patients, 344 patients (69.5%) who completed the test battery before 31 October 2005 were included in this study. All 344 patients were evaluated by neurological and psychological examinations, and chromosomally and endocrinologically screened. All participants signed an informed consent form. Of 344 patients, 227 (66.0%) were the female-tomale (FTM) type, and 117 (34.0%) were the male-tofemale (MTF) type. The mean age at first examination was significantly lower in the FTM type GID patients (mean = 26.7 years, SD = 5.6) than the MTF type (mean = 33.4 years, SD = 10.2) [t(153) =-6.625, P < 0.001]. Other demographic characteristics of the patients are shown in Table 1. The level of education was higher among MTF GID patients than among FTM GID patients (Table 1). The presence of a steady partner was more frequent in the FTM GID group (Table 1). Measures of stress-coping strategies Coping by the patients with GID was evaluated using the Lazarus Stress-coping Inventory, 12 the Japanese version of the Ways of Coping Questionnaire. 12,13 The questionnaire consists of 64 items. Subjects were asked to recall a recent stressful situation and to indicate how much each of the items was used in the situation as a rating on a 3-point scale consisting of not used, used somewhat and used a great deal.

3 Psychiatry and Clinical Neurosciences 2009; 63: Stress-coping strategies in GID 717 Table 1. Demographic characteristics of patients with gender identity disorder Variables MTF n (%) FTM n (%) n Age (years) (22) 89 (39) (17) 79 (35) (22) 34 (15) (39) 25 (11) Age at onset Before elementary 32 (27) 163 (72) school Lower classes in 15 (13) 30 (13) elementary school Higher classes in 16 (14) 20 (9) elementary school Junior high school 26 (22) 11 (5) Senior high school and thereafter 28 (24) 3 (1) Stage of therapy at first examination Without therapy 53 (45) 132 (58) Hormonal therapy 50 (43) 64 (28) without genital plasticity With genital plasticity 14 (12) 31 (14) MTF/FTM, c 2 -test P = Level of education University or higher 52 (44) 47 (21) High school 53 (46) 149 (65) Junior high school 12 (10) 31 (14) MTF/FTM, c 2 -test P = Steady partner Present 43 (37) 144 (63) Absent 74 (63) 83 (37) MTF/FTM, c 2 -test P = Job Employed 85 (73) 174 (77) Unemployed 32 (27) 53 (23) MTF/FTM, c 2 test P = FTM, female-to-male type; MTF, male-to-female type. The instrument includes eight subscales: confrontative coping (aggressive efforts to alter the situation), distancing (efforts to detach oneself), self-control (efforts to regulate one s own feelings and actions), seeking social support (efforts to seek informational support and emotional support), accepting responsibility (acknowledging one s own role in the problem with a concomitant theme of trying to put things right), escape/avoidance (wishful thinking and behavioral efforts to escape or avoid), planful problem-solving (deliberate problem-focused efforts to alter the situation), positive reappraisal (efforts to create positive meaning by focusing on personal growth). Statistical analysis Statistical analysis was conducted using SPSS 14.0J (SPSS Inc., Chicago, IL, USA). The difference of the proportion of MTF and FTM GID patients among groups were evaluated using the c 2 -test. A comparison of coping strategies between the two groups was performed using independent sample t-tests. Comparisons among three groups were evaluated using one-way ANOVA. Tukey s post hoc description was applied if differences were found. The significance level was set at P < RESULTS Table 2 shows that FTM GID patients scored significantly higher on positive reappraisal and distancing subscales than MTF type GID patients. Table 3 shows that the groups aged scored significantly higher on distancing than the groups aged 24 and 35. The group aged had a tendency to score higher on distancing than the group aged There were no significant differences in stresscoping strategies between groups of patients with and Table 2. Differences in coping between MTF and FTM type GID patients MTF FTM P n Planful problem solving Confrontative coping Seeking social support Accepting responsibility Self-controlling Escape-avoidance Distancing Positive reappraisal Scores were measured using the Japanese version of the Ways of Coping Questionnaire. Planful problem solving to positive reappraisal in the left column indicate its subscales. FTM, female-to-male type; GID, gender identity disorder; MTF, male-to-female type; P, independent sample t-test.

4 718 Y. Matsumoto et al. Psychiatry and Clinical Neurosciences 2009; 63: Table 3. Differences in coping among different age groups Age (years) P n MTF/FTM 25/89 20/79 26/34 46/ Planful problem solving Confrontative coping Seeking social support Accepting responsibility Self-controlling Escape-avoidance Distancing Positive reappraisal Tukey s post hoc description; distancing: > 24, P = 0.015; > 35, P = 0.020, > 30 34, P = Scores were measured using the Japanese version of the Ways of Coping Questionnaire. Planful problem solving to positive reappraisal in the left column indicate its subscales. FTM, female-to-male type; MTF, male-to-female type; P, one-way ANOVA. without jobs and/or partners (Table 4). There were also no significant differences in stress-coping strategies among groups divided on the basis of stage of therapy or level of education (Table 5). DISCUSSION Coping and gender difference Coping is defined as a person s constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the person s resources. 10 There have been several studies on gender differences in coping style in the medical literature Several reports have found significant gender differences in coping style. In a study on coping styles for controlling pain in randomly selected households, women reported using significantly more problem solving, social support, positive selfstatements, and palliative behaviors than men did. 14 Among individuals with noise-induced hearing loss, the women used maladaptive behavior and verbal strategies significantly more often than the men. 15 For Table 4. Differences in coping between groups with and without a job and/or partner Job Partner Employed Unemployed P Present Absent P n Planful problem solving Confrontative coping Seeking social support Accepting responsibility Self-controlling Escape-avoidance Distancing Positive reappraisal Scores were measured with the Japanese version of the Ways of Coping Questionnaire. Planful problem solving to positive reappraisal in the left column indicate its subscales. P, independent sample t-test.

5 Psychiatry and Clinical Neurosciences 2009; 63: Stress-coping strategies in GID 719 Table 5. Differences in coping among groups divided on the basis of stage of therapy and level of education Stage of therapy Level of education Without therapy Hormonal therapy Genital plasticity P Junior high school High school University P n Planful problem solving Confrontative coping Seeking social support Accepting responsibility Self-controlling Escape-avoidance Distancing Positive reappraisal Scores were measured with the Japanese version of the Ways of Coping Questionnaire. Planful problem solving to positive reappraisal in the left column indicate its subscales. P, one-way ANOVA; University, university or higher. infertility stress, women used proportionately greater amounts of confrontative coping, accepting responsibility, seeking social support and escape/avoidance when compared with men, whereas men used proportionately greater amounts of distancing, selfcontrolling, and planful problem-solving. 16 Among patients with progressive muscular diseases, women used seeking social support more frequently than men. 17 In another report, there was no statistically significant difference in coping styles between men and women for patients undergoing hemodialysis. 18 These results were not consistent and we could not categorize a consistent gender difference in coping behaviors. The difference in the diseases that subjects suffer from might affect the results. In our study, FTM GID patients were more reliant on positive reappraisal and distancing than MTF GID patients. In particular, the difference in the score of positive reappraisal between FTM and MTF GID patients was not explained by other demographic characteristics (age, stage of therapy, level of education, presence or absence of a job or partner). Therefore, we suppose that gender difference in GID patients might influence the usage of positive reappraisal strategies. Positive reappraisal describes efforts to create positive meaning by focusing on personal growth (e.g. I changed or grew as a person in a good way, I came out of the experience better than I went in ). It also has a religious tone (e.g. I found new faith, I prayed ). 10 What causes the gender difference in using positive reappraisal? In most studies, MTF GID patients were more frequent than FTM GID patients (MTF : FTM = 2 3:1). However, in our study, the proportion of FTM and MTF GID patients is reversed. One significant factor affecting the proportion of each diagnosis in this study may be referral bias because in Japan, MTF GID patients can obtain vaginoplasty relatively easily, whereas the GID Clinic of Okayama University Hospital is the only facility in western Japan that can skillfully perform phalloplasty surgery for FTM GID patients. As a result, FTM GID patients might come to our center more frequently. In particular, most FTM GID patients in our clinic have a clear intention to undergo sexual rearrangement surgery and come to our clinic in earnest. This might influence the gender difference in using positive reappraisal. Coping and other demographic characteristics GID patients in their late twenties had a tendency to be more reliant on distancing than GID patients in other age groups (Table 3). Distancing describes efforts to detach oneself (e.g. I didn t let it get to me, I refused to think about it too much, I tried to forget the whole thing ). Another theme concerns creating a positive outlook (e.g. I made light of the situation and refused to get too serious about it, I looked for the silver lining; I tried to look on the bright side of things ). 10 There have been a few studies on the difference in coping strategies in different age groups. One comparison study among different age groups

6 720 Y. Matsumoto et al. Psychiatry and Clinical Neurosciences 2009; 63: revealed that in healthy individuals, controllability of outcome predicted the use of self-blame among adolescents, while an internal locus of causality of the stressful event predicted self-blame among older adults. 19 Patients on hemodialysis between the ages of 50 and 60 used more emotion-focused coping strategies than patients in other age groups. 18 In our study, we did not clearly determine the reason why GID patients in the late twenties were more reliant on distancing than those in other age groups. The comparison of GID patients and control groups, or determination of the characteristics of GID patients in more detail using, for example, a personality trait test or subjective quality of life scale, might shed more light on this phenomenon. Limitations of this study Some limitations of this study have to be considered. Firstly, this study is a clinic-based study rather than a field study. Therefore, the sample is large, but not necessarily representative of all GID individuals. As stated above, in our study, 60.3% were FTM GID patients, and 39.7% were the MTF type. This proportion is not common in studies on GID. Secondly, we could not clarify the reason why the specific differences of coping strategies were found between genders or among different age groups. Further investigation in the future is needed to clarify the reason. ACKNOWLEDGMENTS We wish to thank Ms Ogino and Ms Kanamori for their skillful assistance in this study. This study is partly supported by a grant from the Zikei Institute of Psychiatry. REFERENCES 1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. APA, Washington DC, Roberto LG. Issues in diagnosis and treatment of transsexualism. Arch. Sex. Behav. 1983; 12: Landen M, Walinder J, Lundstrom B. Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatr. Scand. 1996; 93: Landen M, Walinder J, Lundstrom B. Incidence and sex ratio of transsexualism in Sweden. Acta Psychiatr. Scand. 1996; 93: Okabe N, Sato T, Matsumoto Y, Ido Y, Terada S, Kuroda S. Clinical characteristics of patients with gender identity disorder at a Japanese gender identity disorder clinic. Psychiatr. Res. 2008; 157: Wallien MS, Swaab H, Cohen-Kettenis PT. Psychiatric comorbidity among children with gender identity disorder. J. Am. Acad. Child Psychiatry 2007; 46: Hepp U, Kraemer B, Schnyder U, Miller N, Delsignore A. Psychiatric comorbidity in gender identity disorder. J. Psychosom. Res. 2005; 58: Folkman S, Lazarus RS. An analysis of coping in a middleaged community sample. J. Health Soc. Behav. 1980; 21: Folkman S, Lazarus RS. If it changes it must be a process: Study of emotion and coping during three stages of a college examination. J. Pers. Soc. Psychol. 1985; 48: Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. J. Pers. Soc. Psychol. 1986; 50: Ahlström G, Wenneberg S. Coping with illness-related problems in persons with progressive muscular diseases: The Swedish version of the Ways of Coping Questionnaire. Scand. J. Caring Sci. 2002; 16: Japanese Institute of Health Psychology. Lazarus Type Stress Inventory. Jitsumu Kyoiku Shuppan, Tokyo, Folkman S, Lazarus RS. Manual for the Ways of Coping Questionnaire. Mind Garden, Palo Alto, CA, Unruh AM, Ritchie J, Merskey H. Does gender affect appraisal of pain and pain coping strategies? Clin. J. Pain 1999; 15: Hallberg L. Is there a gender difference in coping, perceived disability and handicap in patients with noise-induced hearing loss? Noise Health 1999; 1: Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how men and women who are referred for IVF cope with infertility stress. Hum. Reprod. 2006; 21: Ahlström G, Wenneberg S. Coping with illness-related problems in persons with progressive muscular diseases: The Swedish version of the Ways of Coping Questionnaire. Scand. J. Caring Sci. 2002; 16: Blake CW, Courts NF. Coping strategies and styles of hemodialysis patients by gender. ANNA J 1996; 23: Blanchard-Fields F, Robinson SL. Age differences in the relation between controllability and coping. J. Gerontol. 1987; 42: