Health, disability and quality of life among trans people in Sweden-a web-based survey

Galit Zeluf, Cecilia Dhejne, Carolina Orre, Louise Nilunger Mannheimer, Charlotte Deogan, Jonas Höijer, Anna Ekéus Thorson, Galit Zeluf, Cecilia Dhejne, Carolina Orre, Louise Nilunger Mannheimer, Charlotte Deogan, Jonas Höijer, Anna Ekéus Thorson

Abstract

Background: Swedish research concerning the general health of trans people is scarce. Despite the diversity of the group, most Swedish research has focused on gender dysphoric people seeking medical help for their gender incongruence, or on outcomes after medical gender-confirming interventions. This paper examines self-rated health, self-reported disability and quality of life among a diverse group of trans people including trans feminine, trans masculine, and gender nonbinary people (identifying with a gender in between male of female, or identify with neither of these genders) as well as people self-identifying as transvestites.

Methods: Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable regression analyses were performed. Three backward selection regression models were conducted in order to identify significant variables for the outcomes self-rated health, self-reported disability and quality of life.

Results: Study participants included 796 individuals, between 15 and 94 years of age who live in Sweden. Respondents represented a heterogeneous group with regards to trans experience, with the majority being gender nonbinary (44 %), followed by trans masculine (24 %), trans feminine (19 %) and transvestites (14 %). A fifth of the respondents reported poor self-rated health, 53 % reported a disability and 44 % reported quality of life scores below the median cut-off value of 6 (out of 10). Nonbinary gender identity (adjusted Odds Ratio (aOR) = 2.19; 95 % CI: 1.24, 3.84), negative health care experiences (aOR = 1.92; 95 % CI: 1.26, 2.91) and not accessing legal gender recognition (aOR = 3.06; 95 % CI: 1.64, 5.72) were significant predictors for self-rated health. Being gender nonbinary (aOR = 2.18; 95 % CI: 1.35, 3.54) and history of negative health care experiences (aOR = 2.33; 95 % CI: 1.54, 3.52) were, in addition, associated with self-reported disability. Lastly, not accessing legal gender recognition (aOR = 0.32; 95 % CI: 0.17, 0.61) and history of negative health care experiences (aOR = 0.56; 95 % CI: 0.36, 0.88) were associated with lower quality of life.

Conclusions: The results of this study demonstrate that the general health of trans respondents is related to vulnerabilities that are unique for trans people in addition to other well-known health determinants.

Keywords: Gender dysphoria; Gender expression; Gender identity; Gender nonbinary; Legal gender recognition; Quality of life; Self-rated health; Self-reported disability; Sweden; Trans; Trans experience; Transgender; Transvestite.

References

    1. Beek TF, Cohen-Kettenis PT, Kreukels BPC. Gender incongruence/gender dysphoria and its classification history. Int Rev Psychiatry Abingdon Engl. 2016;28:5–12. doi: 10.3109/09540261.2015.1091293.
    1. Tate CC, Ledbetter JN, Youssef CP. A two-question method for assessing gender categories in the social and medical sciences. J Sex Res. 2013;50:767–776. doi: 10.1080/00224499.2012.690110.
    1. Department of Gender, Women and Health; World Health Organization (WHO) Gender mainstreaming for health managers: a practical approach. Geneva: World Health Organiztion; 2011.
    1. Bauer G. Making Sure Everyone Counts: Considerations for Inclusion, Identification and Analysis of Transgender and Transsexual Participants in Health Surveys. In: Institute of Gender and Health CIoHR, editor. What a Difference Sex and Gender Make: A Gender, Sex and Health Research Book. Vancouver, British Columbia: Institute of Gender and Health, Canadian Institutes of Health Research; 2012. pp. 59–67.
    1. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS One. 2011;6:e16885. doi: 10.1371/journal.pone.0016885.
    1. Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. J Sex Res. 2015;52:1–14. doi: 10.1080/00224499.2014.893553.
    1. Kuper LE, Nussbaum R, Mustanski B. Exploring the diversity of gender and sexual orientation identities in an online sample of transgender individuals. J Sex Res. 2012;49:244–254. doi: 10.1080/00224499.2011.596954.
    1. Van Caenegem E, Wierckx K, Elaut E, Buysse A, Dewaele A, Van Nieuwerburgh F, et al. Prevalence of gender nonconformity in flanders, belgium. Arch Sex Behav. 2015;44:1281–1287. doi: 10.1007/s10508-014-0452-6.
    1. Lawrence AA. Transgender health concerns. In: The health of sexual minorities. Springer; 2007. pp. 473–505.
    1. Meyer IH. Prejudice and discrimination as social stressors. In: The health of sexual minorities. Springer; 2007. pp. 242–267.
    1. Lombardi E. Enhancing transgender health care. Am J Public Health. 2001;91:869–872. doi: 10.2105/AJPH.91.6.869.
    1. Rotondi NK, Bauer GR, Scanlon K, Kaay M, Travers R, Travers A. Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Can J Commun Ment Health. 2012;30:135–155. doi: 10.7870/cjcmh-2011-0021.
    1. Colizzi M, Costa R, Todarello O. Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study. Psychoneuroendocrinology. 2014;39:65–73. doi: 10.1016/j.psyneuen.2013.09.029.
    1. Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15:525. doi: 10.1186/s12889-015-1867-2.
    1. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. J Homosex. 2006;51:53–69. doi: 10.1300/J082v51n03_04.
    1. Bockting W. Psychotherapy and the real-life experience: From gender dichotomy to gender diversity. Sexologies. 2008;17:211–224. doi: 10.1016/j.sexol.2008.08.001.
    1. Cruz TM. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc Sci Med. 1982;2014:110.
    1. Lombardi E. Varieties of transgender/transsexual lives and their relationship with transphobia. J Homosex. 2009;56:977–992. doi: 10.1080/00918360903275393.
    1. Landén M, Wålinder J, Lundström B. Clinical characteristics of a total cohort of female and male applicants for sex reassignment: A descriptive study. Acta Psychiatr Scand. 1998;97:189–194. doi: 10.1111/j.1600-0447.1998.tb09986.x.
    1. Bodlund O, Kullgren G. Transsexualism—general outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex. Arch Sex Behav. 1996;25:303–316. doi: 10.1007/BF02438167.
    1. Lindemalm G, Körlin D, Uddenberg N. Long-term follow-up of “sex change” in 13 male-to-female transsexuals. Arch Sex Behav. 1986;15:187–210. doi: 10.1007/BF01542412.
    1. Landen M, Wålinder J, Hambert G, Lundström B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998;97:284–289. doi: 10.1111/j.1600-0447.1998.tb10001.x.
    1. Lindemalm G, Körlin D, Uddenberg N. Prognostic factors vs. outcome in male-to-female transsexualism. Acta Psychiatr Scand. 1987;75:268–274. doi: 10.1111/j.1600-0447.1987.tb02788.x.
    1. Wålinder J, Thuwe I, Jacobs A. A social-psychiatric follow-up study of 24 sex-reassigned transsexuals. Göteborg, Sweden: Scandinavian University Books; 1975.
    1. Berg JEA, Gustafsson M. Long term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997;31:39–45. doi: 10.3109/02844319709010503.
    1. Johansson A, Sundbom E, Höjerback T, Bodlund O. A five-year follow-up study of Swedish adults with gender identity disorder. Arch Sex Behav. 2010;39:1429–1437. doi: 10.1007/s10508-009-9551-1.
    1. World Health Organization . Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Tenth Revision. Geneva: World Health Organiztion; 1992.
    1. Ministry of Employment. Equal rights and opportunities regardless of sexual orientation, transgender identity or expression. Factsheet [Internet]. 2013. Available: .
    1. Folkhälsomyndigheten (The Public Health Agency of Sweden). Health and health determinants among transgender persons - a report on the health status of transgender persons in Sweden [Internet]. Stockholm: Folkhälsomyndigheten; 2015. Available: .
    1. Folkhälsomyndigheten (The Public Health Agency of Sweden). The National Public Health Survey 2015 (Hälsa på lika villkor) [Internet]. 17 Nov 2015. Available: .
    1. Budge SL, Rossman HK, Howard KA. Coping and psychological distress among genderqueer individuals: The moderating effect of social support. J LGBT Issues Couns. 2014;8:95–117. doi: 10.1080/15538605.2014.853641.
    1. Harrison J, Grant J, Herman JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy J Harv Kennedy Sch. 2012;2.
    1. Meyer IH. Prejudice, social stress, and mental health in lesbian, Gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674–697. doi: 10.1037/0033-2909.129.5.674.
    1. Richards C, Bouman WP, Seal L, Barker MJ, Nieder TO, T’Sjoen G. Non-binary or genderqueer genders. Int Rev Psychiatry Abingdon Engl. 2016;28:95–102. doi: 10.3109/09540261.2015.1106446.
    1. Folkhälsomyndigheten (The Public Health Agency of Sweden). The right to health – how norms and structures affect transgender people’s experiences of sexual health [Internet]. Stockholm: Folkhälsomyndigheten; 2016. Available: .
    1. Dhejne C, Vlerken RV, Heylens G, Arcelus J. Mental health and gender dysphoria: A review of the literature. Int Rev Psychiatry. 2016;28:44–57. doi: 10.3109/09540261.2015.1115753.
    1. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103:1820–1829. doi: 10.2105/AJPH.2012.300796.
    1. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf) 2010;72:214–231. doi: 10.1111/j.1365-2265.2009.03625.x.
    1. Weyers S, Elaut E, De Sutter P, Gerris J, T’Sjoen G, Heylens G, et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med. 2009;6:752–760. doi: 10.1111/j.1743-6109.2008.01082.x.
    1. Motmans J, Meier P, Ponnet K, T’Sjoen G. Female and male transgender quality of life: socioeconomic and medical differences. J Sex Med. 2012;9:743–750. doi: 10.1111/j.1743-6109.2011.02569.x.
    1. Kuhn A, Bodmer C, Stadlmayr W, Kuhn P, Mueller MD, Birkhauser M. Quality of life 15 years after sex reassignment surgery for transsexualism. Fertil Steril. 2009;92:1685–1689. doi: 10.1016/j.fertnstert.2008.08.126.
    1. Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work. 2015;40:134–141. doi: 10.1093/hsw/hlv025.
    1. Rosser BS, Oakes JM, Bockting WO, Miner M. Capturing the social demographics of hidden sexual minorities: An Internet study of the transgender population in the United States. Sex Res Soc Policy. 2007;4:50–64. doi: 10.1525/srsp.2007.4.2.50.
    1. Gomez-Gil E, Zubiaurre-Elorza L, de Antonio IE, Guillamon A, Salamero M. Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2014;23:669–676. doi: 10.1007/s11136-013-0497-3.
    1. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health. 2012;102:118–122. doi: 10.2105/AJPH.2011.300315.
    1. Grossman AH, D’augelli AR. Transgender Youth. J Homosex. 2006;51:111–128. doi: 10.1300/J082v51n01_06.
    1. Toomey RB, Ryan C, Diaz RM, Card NA, Russell ST. Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and young adult psychosocial adjustment. Dev Psychol. 2010;46:1580–1589. doi: 10.1037/a0020705.
    1. Helgeson VS. Social support and quality of life. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2003;12(Suppl 1):25–31. doi: 10.1023/A:1023509117524.
    1. Molarius A, Berglund K, Eriksson C, Lambe M, Nordström E, Eriksson HG, et al. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health. 2007;17:125–133. doi: 10.1093/eurpub/ckl070.
    1. Davey A, Bouman WP, Arcelus J, Meyer C. Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls. J Sex Med. 2014;11:2976–2985. doi: 10.1111/jsm.12681.
    1. Factor RJ, Rothblum ED. A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence. J LGBT Health Res. 2008;3:11–30. doi: 10.1080/15574090802092879.
    1. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance–rejection among transwomen of color. J Fam Psychol. 2009;23:853. doi: 10.1037/a0017198.
    1. Santos G-M, Rapues J, Wilson EC, Macias O, Packer T, Colfax G, et al. Alcohol and substance use among transgender women in San Francisco: prevalence and association with human immunodeficiency virus infection. Drug Alcohol Rev. 2014;33:287–295. doi: 10.1111/dar.12116.
    1. Reisner SL, Gamarel KE, Nemoto T, Operario D. Dyadic effects of gender minority stressors in substance use behaviors among transgender women and their non-transgender male partners. Psychol Sex Orientat Gend Divers. 2014;1:63–71. doi: 10.1037/0000013.
    1. Operario D, Yang M-F, Reisner SL, Iwamoto M, Nemoto T. Stigma and the syndemic of hiv-related health risk behaviors in a diverse sample of transgender women. J Community Psychol. 2014;42:544–557. doi: 10.1002/jcop.21636.
    1. Kosciw JG, Palmer NA, Kull RM. Reflecting resiliency: openness about sexual orientation and/or gender identity and its relationship to well-being and educational outcomes for LGBT students. Am J Community Psychol. 2015;55:167–178. doi: 10.1007/s10464-014-9642-6.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi