July 12, 2011

Study on differences in mental health between homosexual and heterosexual transsexuals

Are gynephilic (woman loving)  transwomen more likely to suffer from mental illnesses than the androphilic (man loving) ones? And what about transmen? 

The question of whether there are different types of transsexuals is one of the minefields of transgender research, not at least because there is a long tradition to consider transwomen who love women fakes or perverts. The idea that transsexuals can be gay or lesbians too, seems to be hard to understand.  Both doctors and many "classic transsexuals" have considered the other kind to be fetishistic crossdressers and perverted "autogynephiliacs". 

An underpinning assumption has been that gynephilic (woman-loving) transwomen are mentally ill, while the the androphiles (man-lovers) are either "real women" ("real women love men") or -- as in the teachings of Ray Blanchard -- mentally healthy feminine gay men.

This debate is also of relevance to non-transsexual transgender people, especially if you believe there are common traits between crossdressers and crossdreamers on the one hand and transsexuals on the other. I believe there are, given that so many transsexuals have been  crossdreamers and/or crossdressers before transitioning.  

The MMPI-2/MMPI-A study

A  new Dutch study,"Comparing adult and adolescent transsexuals: An MMPI-2 and MMPI-A study",  looks into the mental health of transsexuals and presents some very interesting findings.

As always, remember that research is a work in progress, and that gender research is doubly so, given all the difficulties stemming from the cultural context, methodological problems, the prejudices of the researchers etc. etc. In this post I consider the findings as they are. 

Cause and effect, causality and correlation

What makes such studies hard is that it is hard to distinguish between cause and effect: 

Are transsexuals mentally ill? 

If they are ill: Does the mental illness cause their transsexual condition or is it their transsexual condition that makes them ill? 

If their their illness is caused by their transsexuality, is this for inborn reasons or because of the way people treat them?

The social and cultural context of transsexuals shape their life trajectories

I have previously put forward the following hypotheses:

  1. Male to female transwomen are more likely to suffer from mental illnesses than female to male transwomen, as it is more stigmatizing for a male bodied person to say that she wants to be a woman than it is for a female bodied person to say that he wants to become a man.

    The reason for this is that we live in a society that continue to think that men are stronger and "better" than women, in spite of all the talk about gender equality. I think many continue to think unconsciously of women as castrated and weak men, in a "how big is yours?" kind of way.

    In Western countries women are therefore given much more freedom when it comes to take up male interests, mannerisms, clothing and behavior than the other way round, most likely because male interests are imbued with power and prestige.

  2. I have believed that gynephilic   transwomen would be more likely to suffer from mental illnesses than androphilic  transwomen.

    A majority of male to female transwomen are lesbians (gynephilic). This puts them in a position that is very different from the androphilic. While the androphilic male to female transperson may adapt the feminine behavior and symbols of her culture and have a realistic hope of attracting a male partner, a gynephilic one will find this much harder. Western women are rarely brought up to go for "a man in a dress".

    Moreover: In the West the androphilic transwomen may find role-models and friends in the gay community, which might allow them to explore their sexuality even before transitioning.

    This means that both androphilic and gynephilic M2F transpersons will suffer for their "transgressions", but in different ways.

  3. I have argued that the reason androphilic transwomen are less likely to report erotic crossdreamer fantasies may be exactly this: It may be easier for them to find compatible lovers, even when in a male body. Having a healthy love life -- with all the social and psychological confirmation that follows -- seems to me to be an essential prerequisite for developing an emotionally stable psyche. They will therefore interpret their own sexual fantasies as non-autogynephilic, even if the "stories" of these fantasies are more or less the same as the ones of the gynephilic ones.

    The gynephilic transwomen, on the other hand, will try much harder to live the life of a man, believing that that is the only way to get find a female lover and friend. That is not an unrealistic assumption, due to the lack of compatible female sex partners.

    That leads them onto a path of self denial and painful sacrifices. To the extent they express their female side, it is through closeted crossdressing and crossdreaming fantasies, which again leads to them being labelled as narcissistic perverts.
So much for the hypotheses. The Dutch study strengthens one of them, but weakens the other.

Previous research

The authors point to the fact that previous research has been inconclusive as regards the mental health of transsexuals. Some studies show female to male transsexuals (FtMs) to function psychosocially better than the male to female (MtF) counterpart.  Other studies have failed to detect this difference.

The authors point to the subdivision made by Blanchard and others, i.e. that there are two types of MtF transsexuals: the androphilic (called "homosexual" by  Blanchard) and the gynephilic/asexual/bisexual (called "non-homosexual"). 

The authors do not mention this directly, but it is clear that Blanchard considers the "homosexuals" mentally healthy, while the "non-homsexuals" are considered paraphilic (sexually perverted). There is no previous research documenting the differences in mental health of these two groups.

Finally, some studies have shown that younger transitioners are more likely to show a good prognosis than those that transition late.

The respondents

In order to test all of this the researchers tested several groups of transsexuals who had been treated at the Amsterdam VU University Medical Centre:
  • 207 adult MtFs (male to females, mean age 38) Of these 59 were androphilic (33%) and 116 non-androphilic (66%).
  • 86 adult FtMs (female to males, mean age 33) Of these 58 were gynephilic (77%), while 17 were non-gynephilic (33%).
  • 43 adolescent MtFs (mean age 16) All were androphilic.
  • 40 adolescent FtMs (mean age 16) All were gynephilic.
Note that a majority of the MtFs transwomen were non-androphilic, i.e. lesbian or bisexual. A majority of the FtM transmen were gynephilic. The two groups do not mirror each other in this respect. Exactly why this is so, is not explained. I suspect this has to do with our culture's higher tolerance for bisexuality among female bodied persons.

As is to be expected from the argument I have made above, young "transitioners" are more likely to be attracted to the opposite sex. 

In this study all of the young transwomen were androphilic.

The psychological profiling

In order to test the mental health of the respondents the researchers made use of two questionnaires, the MMPI-2 for grown ups and the MMPI-A for the youngsters. 

I am in no position to make any judgments about the quality of these questionnaires. The fact that "hysteria" is one of the conditions listed is disturbing, as the term is rarely in modern psychiatry, but there is nothing I can do about that.

Psychological functioning is measured in so-called T-scores. This may sound intimidating, but isn't. Think of this as a linear scale between 0 and 100. A t-score of 50 means average. A score between 45 and 65 is within the normal rage.

The results

As in most studies of this kind all mean T-scores except one were within the normal range. 

The exception was "the mean Psychopatic Deviate score". The authors explain this in this way:

 "In transsexuals, such high scores may be expected, because this scale largely reflects interpersonal difficulties. As transsexualism is a poorly accepted phenomenon, a negative attitude of the environment to the person who is pursuing sex reassignment may be most severe early in the diagnostic procedure, when the MMPI [test] was administered."

So on average, the transsexuals looked pretty healthy, mental wise. That doesn't mean that none of them were in "the clinical range", i.e. showing score that puts them in the mentally ill category. 35 percent of the adult transsexuals scored in the clinical range on more than four clincal scales.

The authors interprets this to mean that there are subgroups with psychopathology that may be related to sex, sexual orientation or age.

The FtMs do better

My hypothesis that FtM transmen will be psychologically speaking healthier than their MtF counterpart is supported by the study:

"In line with several other studies, our adult FtMs functioned psychologically better than adult MtFs. One of the reasons might be that FtMs, in comparison to MtFs, pass more easily in the opposite gender role."

Young transsexuals do better

The adolescents also seem to be psychologically healthier than the adults. Again the researchers are good at contextualizing their findings:

"Likewise, the absence of sex differences in psychological functioning in our adolescent sample might be associated with their more convincing appearance, as they have not yet developed secondary sex characteristics."

The researchers suggest that it is probably easier to make a gender role change around the start of puberty than in adulthood:

"Young transsexuals might be less harmed by the consequences of their gender dysphoria, such as stigmatization."

Note that the fact that young transsexuals are less likely to report psychological problems, indicates that the psychopathology found in adult transsexuals is most likely caused by the transgender condition, and not the cause of it.

The only finding that could weaken this conclusion would be if you can show that there is a difference between various subgroups of transsexuals. 

Note that all the young transsexuals in this sample are heterosexual (i.e. attracted to the sex opposite to the sex they identify with). These are the ones Blanchard and the authors of this paper calls "homosexuals". You could argue that the good mental health of the youngsters is a result of their sexual orientation, while the lesbian MtF transwomen and the gay FtM transmen are all mentally disturbed.

No significant difference between "homosexual" and "non-homosexual" transsexuals

Indeed, the researchers had clearly expected to find more mental illness among the non-androphilic transwomen than the androphilic ones. After all, one of the key messages from researchers like Blanchard is that the non-androphilic "autogynephiliacs" are mentally disturbed by definition, while the "homosexual transsexuals" are not.

I have even seen similar theories pop up in crossdreamer circles. One popular theory is that there is a correlation between Aspberger /ADHD and crossdreaming. 

I have been skeptical, as I have suspected that people mistake natural introversion and shyness for Aspbergers. I have argued that  that natural shyness could have been reinforced by a transgender condition, as the persons' confusion as regards body image and social roles could have led to even more intense social awkwardness. I know this from my own life experience.

I have believed that the reason androphilic transwomen appear more outgoing and self confident could simply be an effect of them transitioning earlier. They will look younger and more feminine and  therefore "pass" more easily, which would increase the chances of them getting confirmation of their femininity from the people they meet. This would then lead to less psychological stress compared to the gynephiles.

(Note, i am speaking in relative terms here. They all go through hell, and not all of them come back again!)

It seems I was wrong about this.

"Contrary to our expectations," the researchers write, "there appeared to be hardly any difference in psychological functioning between 'homosexual' and 'non-homosexual' transsexuals...It could be that 'homosexual' and 'non-homosexual' transsexuals are after all not so different with regard to their psychological functioning." (My emphasis)

The researchers therefore argue that a classification based on sexual orientation should  be used carefully in clinical practice, "as the relationship with comorbid psychopathology is less clear than often assumed." 

I take that as an indirect critique of Ray Blanchard's insistence on there being two distinct types of transsexuals. One of the authors, Peggy T. Cohen-Kettenis, is actually member of the same DSM-5 workgroup as Blanchard. I do hope she brings this research to the attention of the rest of the group.

So I stand corrected. If these results are correct my idea of androphilic transwomen being more emotionally stable than the gynephilic ones is wrong.

An explanation for the equal level of distress

My mistake may be caused by me underestimating other types of social dismissal. Julia Serrano, transwoman, trans-activist and previous crossdreamer, makes  a very pertinent observation in her book, Whipping Girl:

"I was sometimes teased for being different, for being an atypical or unmasculine boy, but it was nothing compared to venom that was reserved for those boys who acted downright feminine." (p. 3)

In other words, young androphilic transgirls may be interpreted to be "effeminate sissies", and for a male bodied kid that is a social kiss of death. They may indeed make better use of -- and gain respect for -- their more outspoken femininity in alternative circles, when they grow up, but as long as they stay among the muggles they are bound to be harassed even more severely than  less flamboyant transkids.

The only significant differences the researchers could find between the two groups of transwomen was that the androphilic scored significantly higher on the Schizophrenia scale compared to the non-androphilic. I don't know what to make out of that. 

What really surprised me, however, was the fact that the two groups score more or less the same on Social Introversion and Depression, and both groups are within the normal -- non-pathological -- range!

It could be that the introversion and shyness I see among many non-op M2F crossdreamers is an effect of the shy ones being more likely to explore their transgender condition online. Or maybe their shyness makes it less likely for them to seek SRS.


What seriously bothers me with studies like this one, is that the researchers continue to feel compelled to react to Blanchard and similar researchers. I guess it is good for comparability, but it also means that some of the underpinning ideology follows with the methodology.

It is, for instance, completely unnecessary to use the offensive term "homosexual" for heterosexual transwomen. You can use "androphilic" instead.

By sticking to Blanchard's two category model, "homosexual" vs. "non-homosexual", they also end up sorting out a lot of valuable data even before the study has begone. Many transwomen will tell you that they do not feel at home in a scheme that does not take bisexuality and asexuality seriously. 

The researchers are aware of the problem:

"As sexual orientation consists of various components (romantic attraction, sexual behavior and sexual identity), people may have responded to different aspects. In addition, sexual orientation can change during a person's lifetime, and this may be particularly true for young women."

And then they make a very important observation, which I find extremely interesting:

"Regarding transsexual individuals especially, it could be difficult to identify as 'homosexual' or 'non-homosexual', as their sexually orientation may be obscured by their gender dysphoric feelings."

I take this to mean that some transsexuals (and in other gender dysphoric transgendered persons) may suppress their trues sexual orientation in order to fit into the expected pattern of behavior.

From what I see in crossdreamer and transgender circles I doubt that this applies to their basic sexual orientation. Most M2F crossdreamers are -- for instance -- to gynephilic for that to be the case. It could be, however, that our social conditioning weakens a more common sexual flexibility or bisexuality.


"Comparing adult and adolescent transsexuals: An MMPI-2 and MMPI-A study",  de Vries,  Kreukels, Steensma, Doreleijers and Cohen-Kettenis in Psychiatric Research (186 (2011) 414–418).

"Sex, sexual orientation and age have been shown to be important in relation to psychological functioning in transsexuals. However, only few studies to date took these factors into account and not earlier have adolescent transsexuals participated. In this study the Minnesota Multiphasic Personality Inventory (MMPI-2 or MMPI-A, respectively) was administered to 293 adults (207 male to female transsexuals (MtFs), mean age 38.04 (range 18.56–65.62) and 86 female to male transsexuals (FtMs), mean age 33.26 (range 18.95–64.30)) and 83 adolescents (43 MtFs, mean age 15.70 (range 13.16–18.70) and 40 FtMs, mean age 15.64 (range 13.05–18.56)) with a gender identity disorder (GID). Of adult MtFs, 33% were categorized as “homosexuals” [in fact: heterosexual, as these are transwomen who love men] and 66% as “non-homosexuals” [meaning non-adrophilic, i.e. woman-loving or bisexual]. Of adult FtMs, 77% were categorized as “homosexuals” and 33% as “nonhomosexuals”. Adult FtMs functioned significantly better than MtFs on three clinical scales. Contrary to what is often assumed, no differences in psychological functioning were found in the adult transsexuals with regard to sexual orientation, except on one clinical scale. Most remarkably, significantly more adults with GID scored in the clinical range on two or more clinical scales than adolescents with GID. Therefore, early medical intervention may be recommendable for adolescents with GID."


  1. "Most M2F crossdreamers are -- for instance -- too gynephilic for that to be the case. It could be, however, that our social conditioning weakens a more common sexual flexibility or bisexuality".

    I think all humans have some degree of bisexuality innate. It is very very rare for true 100% homosexuality or true 100% heterosexuality.
    However,choices matter. I would for example not really go for a masculine man, though a feminine male could always make me hard.
    Again, goes very nicely with the fact that I am gynephilic and also ultrafeminine.

  2. Jack,

    Thanks so much for this blog and all the incredibly valuable information that it contains. I am another AGP Crossdreamer who has longed for years to find a community where trying to understand the phenomenon is a priority.

    I've come to accept it as a part of who I am but am still in the process of how I choose to let it manifest in my life. I use what resources I can to control it and keep it in balance but am committed to learning all I can about it, which is a lifelong mission.

    I look forward to reading more of your great information and links and hope I can make some meaningful contributions as well.


  3. Thanks for the thumbs up, John. I look forward to hearing more from you!

    I think it is time to go more into depth on how crossdreamers can cope living in the bodies God/Nature gave them. Unfortunately there is not much research on that.

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