Body Satisfaction, Sexual Satisfaction, and the
Effect on Treatment Wish
of Individuals with Gender Dysphoria Applying for Medical
Treatment
Masterthesis by Cécile van de Ven
Name: Cécile van de Ven Student number: 10000612 Date: March 24, 2017 MSc Clinical Psychology, Faculty of Social and Behavioral Sciences Supervisors: Jos Bosch; UvA Clinical Psychology,
Faculty of Social and Behavioral Sciences, and Baudewijntje Kreukels; VUmc Center of Expertise on Gender Dysphoria
1. Abstract
Background Individuals with gender dysphoria (GD) are characterized by experiencing an incongruence between the experienced gender and the gender they were assigned to at birth. This is often accompanied by strong dissatisfaction with the body. The first aim of this project was to explore variety within the GD population concerning body satisfaction, sexual satisfaction, and treatment wish. Secondly, the relations between body satisfaction, sexual satisfaction, and the selection of gender confirming interventions (GCIs) were examined. Method A total of 344 individuals who applied for gender-confirming medical treatment at a treatment facility were included in this study, involving 216 male-to-females (MtFs) and 129 female-to-males (FtMs). Body satisfaction was measured using the Body Image Scale (BIS) and sexual satisfaction was assessed using the Background Data Interview (BI). Information on treatment wish was collected using a questionnaire provided by a treatment facility. Results MtFs reported higher dissatisfaction with both their body as a whole and concerning the genital area in comparison to FtMs. FtMs were, in addition to their genital area, the least satisfied with their chest area. FtMs experienced more pleasure when having an orgasm, and MtFs use their genitals more often when having sex. Genital body satisfaction correlates moderately with sexual satisfaction. Together, body satisfaction and sexual satisfaction were predictors for treatment wish: and could predict whether MtFs and FtMs desire a full medical treatment or a partial treatment.
Index
1. Abstract 2
2. Introduction 4
3. Method
3.1 Sample Characteristics 8
3.2 Operationalization and Procedure 8
3.3 Material 8
3.4 Data Analysis 9
4 Results
4.1 Sexual Orientation 10
4.2 Differences in Body Satisfaction 10
4.2.1 Differences Between the Sexes 10
4.2.2 Differences Considering Sexual Orientation 10
4.3 Differences in Sexual Satisfaction Areas 13
4.3.1 Sexual Satisfaction Areas 14
4.3.2 Differences in Sexual Satisfaction Areas between
the Sexes and Sexual Orientation groups 15 4.4 Correlations Between Body Satisfaction, Body Satisfaction Areas,
and Sexual Satisfaction Areas 15
4.4.1 Correlations Between Body Satisfaction and Sexual Satisfaction
Areas 16
4.4.2 Correlations Between Body Satisfaction Areas and Sexual
Satisfaction Areas 16
4.5 The Effect of Satisfaction with the Genital Area and Sexual
Satisfaction Areas on Treatment Wish 18
5 Discussion 19
6 Limitations 23
7 References 24
8 Appendices
8.1 Appendix A: Frequencies and Differences among MtFs and
FtMs concerning Sexual Experience 26
8.2 Appendix B: Body Image Scale (BIS) Male and Female version 27 8.3 Appendix C: Background Data Interview (BI) Male and Female version 29
2. Introduction
Gender dysphoria (GD) is a mental health condition listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2013). The diagnosis covers both ‘gender’ (of an individual) and the word ‘dysphoria’ which means ‘a state of unease or generalized dissatisfaction with life’ (www.oxforddictionaries.com). Individuals with genderdysphoric feelings experience distress as a result of a marked incongruence between the gender they got assigned to at birth and another gender, which they identify with themselves (Judge et al., 2014). Most individuals with GD desire to live as their experienced gender. In order to physically transition from the gender they were assigned to at birth to the gender they identify with, people with GD can choose to apply for medical gender confirming interventions (GCIs) at several treatment facilities specializing in this field.
Medical interventions for adults with a GD diagnosis consist of feminizing/masculinizing hormone treatment and surgical interventions, which vary according to sex assigned at birth (Coleman et al., 2012). In line with Beek, Kreukels, Cohen-Kettenis, and Steensma (2015), male-to-females (MtFs) who desire both hormone treatment and genital surgery are considered those who request ‘full treatment’. Full treatment in female-to-males (FtMs) consists of hormone treatment, a mastectomy (breast removal surgery), hysterectomy (uterus removal surgery) and genital surgery. Any combination of some but not all of these interventions is considered as ‘partial treatment’. Apart from that people can opt for additional interventions, such as facial feminizing surgery (FFs) and breast augmentation surgery in MtFs.
In order for treatment facilities to create the best fitting treatment for each individual, it’s important to examine variety in treatment wish and what underlies these different desires within the GD population. Individuals with GD report various reasons for choosing whether they want full or partial treatment. Beek, et al. (2015) found that full treatment is the most requested option. However, a substantial number of individuals with GD desire partial treatment with the exclusion of genital surgery. The most common reported reason for choosing a partial treatment in FtMs is apprehension about surgical risks or a disappointing outcome (Beek, et al. 2015). In MtFs the most reported reason for choosing partial treatment is the lack of genital dysphoria or a general feeling that genital surgery isn’t a necessity. Since dissatisfaction with the primary sex characteristics is such a central part of GD diagnosis, a lack of genital dysphoria hints at variety within the transgender population. A possible important underlying motive of the desire of a body transition is the degree of satisfaction with one’s genitals. And contemplating a social transition in general, the satisfaction with the body as a whole.
‘Body satisfaction’ has recently gained attention in scientific research in both individuals with GD and ‘cisgender’ (not-gender dysphoric) people with psychiatric disorders. Body satisfaction refers to the multifaceted psychological experience of embodiment, which encompasses one’s body-related self-perceptions and self-attitudes, and is discussed to be even more psychosocially powerful than the social ‘reality’ of body appearance (Cash, 2003). Since body related incongruence is the main focus and difficulty in GD, body satisfaction is discussed and found to be ‘lower’ in transgender individuals in comparison to cisgender individuals (Becker, et al., 2016). This not only includes genital body satisfaction, but also the body as a whole. Although genital body satisfaction seems to be limitedly associated with body satisfaction in general (Van de Grift, et al., 2016a), low body satisfaction in GD concerns both genital and non-genital body areas (Becker et al., 2016). Lindgren and Pauly (1975) introduced the Body Image Scale for Transsexuals (BIS), which allows practitioners to obtain information on body satisfaction in people with GD. Using a five-point scale to assess 30 different body parts, body satisfaction is being measured. Van de Grift, et al. (2016a) confirmed a six-factor model of body satisfaction using the BIS, identifying six body satisfaction
areas: the social and hair region, head and neck region, muscularity and posture, hip region, chest region and the genital area.
There are a number of individual differences that have an impact on body satisfaction. A first factor that should be taken into account when studying the nature of body satisfaction, is sex. Insecurities evolving around the body can differ for men and women, and are greatly influenced by society’s gender norms. A woman’s appeal as a sexual partner seems to be heavily dependent on her visual stimulus value for others (Woertman & Van den Brink, 2012). Body characteristics can be acknowledged as being very ‘masculine’, such as a broad chest and facial hair, or specifically ‘feminine’, such as long hair, and a curvy body type. The masculinity and femininity of the body can be seen as two extremes on a scale, where the utter ends are seen as attractive for cisgender men and cisgender women separately (McCreary & Sasse, 2000; Fink, Klappauf, Brewer, & Shackelford, 2014). Particularly these characteristics are central features in body dissatisfaction among people with GD (Van der Grift et al, 2016b).
Studies that focus on the relationship between sex and body satisfaction in people with GD (Becker, et al. 2016; Van de Grift, et al., 2016b) regularly find lower body satisfaction in females in comparison to males (Fiske, Fallon, Blissmer & Redding, 2014). Van de Grift et al. (2016b) researched body satisfaction in individuals with GD who applied for medical treatment and also found differences between MtFs and FtMs. MtFs scored higher on the BIS, indicating lower body satisfaction. Differences between both cisgender males and females, and between MtFs and FtMs might be explained by the sexualizing of the female body, and the accompanying pressure on adolescent women to have certain measures (Prantl & Gründl, 2011), which can be particularly difficult for MtFs. Subsequently MtFs may experience more dissatisfaction with their bodies than FtMs because a more feminine appearance in natal men is less socially accepted than a more masculine appearance in natal women (Van de Grift, 2016a). According to evolutionary theorists, women’s physical attractiveness is especially important because it gives male sexual partners reliable cues about potential reproductive success. This may have caused women to become—in the course of evolution—increasingly aware of how they appear to others, especially to sexual partners (Woertman, and Van den Brink, 2012). Van der Grift et al. (2016b) also found differences between MtFs and FtMs considering satisfaction with the different body satisfaction areas. Both MtFs and FtMs appeared to be the least satisfied with the genital area and the chest area. In addition, MtFs reported strong dissatisfaction with the social and hair items, where FtMs reported strong dissatisfaction with the hip region. Both areas cover prominent positions on the masculine/feminine scale: facial hair in natal men, and hip width in natal women.
Another factor that can have an effect on body satisfaction is the possibility of experiencing social encounters. Situations in which social encounters take place can be argued as particularly submitted to a focus on the own body. For people with GD who are in a romantic relationship, or for those who aren’t but are sexually interested in other people, body satisfaction may be crucial in regard to intimacy and sex life. Sexual orientation, of both partners, plays a role in this influence, partly because there are different ways in which two people prefer to have sex. In MtFs differences regarding body satisfaction might be present between androphilic individuals, those who are solely attracted towards men, and non-androphilic individuals, those that are not solely attracted towards men, but to women, both men and women or genderdysphoric people. In FtMs those differences might be found between gynephilic individuals, who are solely attracted towards women, and non-gynephilic individuals, those that are not solely attracted towards women. Typologies within the genderdysphoric population are predominantly applied considering sexual orientation sub-groups. Lawrence (2009) emphasized the superiority of using sexual orientation as subgroups over other
non-androphilic). FtM adults predominantly appear to be gynephilic opposed to non-gynephilic (Lawrence, 2009; Kreukels, Haraldsen, De Cuypere, Richter-Appelt, Gijs, & Cohen-Kettenis, 2012; Cerwenka, et al., 2014). Previous studies show contradicting results, but mainly don not find differences in body satisfaction between these subgroups (Van der Grift, et al., 2016b; Becker, et al., 2016).
For both MtFs and FtMs undesirable sex-specific body characteristics can cause significant distress during sexual activities with a partner or alone (Cerwenka, et al. 2014). Milhausen, Buchholz, Opperman, and Benson (2015) however, found among heterosexual cisgender men and women that only for men positive body satisfaction was associated with being sexually satisfied. For women, previous studies find contradicting results regarding the cohesion between body satisfaction and sexual satisfaction, and appoint the influence of additional contributing factors such as being in a satisfying relationship (Milhausen, Buchholz, Opperman, & Benson, 2015). Considering these findings among cisgender individuals, and the additional dissatisfaction with the body genderdysphoric individuals experience, body satisfaction is expected to be linked to sexual satisfaction in individuals with GD as well.
To our knowledge, the relation between sexual satisfaction and body satisfaction in people with GD have not been studied thus far. Sexual satisfaction alone in both MtFs and FtMs has. Cerwenka, et al. (2014) investigated sexual satisfaction before the start of treatment in individuals with GD by means of different areas concerning the experience of sexuality. They found no significant differences between MtFs and FtMs regarding the use of the genitals (when having sex with another person), genital pleasure, and the act of masturbation. However, previous research has found that, before the start of treatment, MtFs use their genitals more often than FtMs when having sex with another person (Selvaggi, et al. 2007; Coleman, et al. 1993; Kraemer, et al. 2010, cited by Cerwenka, et al. 2014). Cerwenka, et al. (2014) did find a significant difference in the pleasure of orgasm, whereby FtMs tend to appraise orgasm more frequently as pleasant. For people with GD who haven’t undergone medical treatment in order to transition, intimacy may be accompanied by a complex combination of feelings that are both positive and negative. The pleasure one experiences when having an orgasm for example, is intertwined with the negative reminder of undesired body characteristics, resulting in negative perceptions of orgasm (Cerwenka, et al. 2014). When comparing MtFs and FtMs this might especially be present in MtFs, because of the masculine characteristics of both the male erection and the male orgasm. Pleasure of orgasm might therefore be an important feature when exploring sexual satisfaction in genderdysphoric individuals. Whether people with GD are sexually satisfied in general is expected to be related to body satisfaction in the way that dissatisfaction with the body correlates with dissatisfaction with their sex lives. This may be particularly apparent for genital body satisfaction in both MtFs and FtMs, and body satisfaction concerning the chest area in FtMs.
When applying for GCIs at a treatment facility ideally many facets of changes that can occur when receiving treatment, are being discussed (WPATH, 2011). This includes positive changes such as an increase in the satisfaction with sex characteristics corresponding with the natal sex, but also negative changes such as disappointing results of bodily changes after hormone treatment and surgery. Although several studies show that medical treatment leads to a decrease in distress, improvement in social and sexual functioning and that medical treatment can alleviate GD (Gijs & Brewaeys, 2007; De Vries, et al. 2014), no studies have shown that genital surgery can resolve GD (Cohen-Kettenis & Gooren, 1999; Smith, Van Goozen, Kuiper, & Cohen-Kettenis, 2005; Murad, Elamin, Garcia, et al. 2010, cited by Gooren, 2011). This indicates that the best possible treatment doesn’t consist of medical gender affirming interventions alone. In order to enlarge the chances to resolve GD, a second factor of influence is important to acknowledge. Redfern and Sinclair (2014) appoint the discussion about realistic expectations of medical treatment as a necessary part of the
diagnostic phase. Both hormonal treatment and surgical treatment can result in very different outcome in different individuals, hence the importance of discussing specifics considering the treatment options. Sexual satisfaction and body satisfaction are expected to improve during treatment, mainly by physical changes following GCIs but, also by the setting of realistic goals and talking about insecurities with a specialized practitioner. For some individuals, a partial treatment, such as hormones, a mastectomy or genital surgery, or a combination of a social transitioning and genital surgery, or even a social transitioning without any medical interventions would be sufficient to alleviate GD (WPATH, 2011). Exploring the variety within the GD population, and exploring the underlying structures that have an impact on this variation, may result in more fitting ‘customized’ care for genderdysphoric individuals applying for GCIs. Body satisfaction and sexual satisfaction in genderdysphoric individuals applying for GCIs at a treatment facility were examined to gain insight in this population. To explore the variety in the population concerning different underlying motives for having a certain treatment wish, body satisfaction and sexual satisfaction were used to examine whether they can predict treatment wish.
The rationale for this study was that body satisfaction, sexual satisfaction and treatment wish in genderdysphoric individuals depend on each other. Secondly, differences between the sexes and sexual orientation groups were expected. Sexual orientation and both body satisfaction and sexual satisfaction separately have been examined in genderdysphoric individuals in previous research. This study will test the 7 following hypotheses, of which the first 4 replicate earlier research:
1. Body satisfaction is expected to be significantly lower in MtFs, compared to FtMs. 2. Considering sexual orientation, no significant differences are expected regarding
body satisfaction.
3. Concerning the different body areas, MtFs are expected to be the least satisfied with the genital, chest, and social and hair areas. FtMs are expected to be the least satisfied with the genital, chest areas and hip region.
4. No significant differences considering natal sex are expected considering the following sexual satisfaction areas: sexual satisfaction in general, masturbation, genital use, genital pleasure and the importance of sex. FtMs are expected to report significantly more pleasure of orgasm in comparison to MtFs.
Cohesion between body satisfaction and sexual satisfaction hasn’t been studied thus far. Correlations between the different areas were expected. Apart from the cohesion of body satisfaction and sexual satisfaction, this study focused on the underlying motives of treatment wish. Body satisfaction and sexual satisfaction were expected to predict treatment wish in individuals with GD. These assumptions were summarized in the following 3 hypotheses that haven’t been studied thus far:
5. Body satisfaction and sexual satisfaction areas were expected to be correlated in all subgroups.
6. Genital body satisfaction was expected to correlate significantly with sexual satisfaction areas in all subgroups.
7. Body satisfaction areas and sexual satisfaction areas were expected to be significant predictors for treatment wish.
3. Method
3.1 Sample Characteristics
All 345 participants in this study were applicants at the Center of Expertise on Gender Dysphoria at the VU university medical center (VUmc), and entered the clinic in 2013. Anyone who is experiencing distress concerning their gender identity and who is looking for medical treatment in order to change their bodies can apply via their general practitioner. The first clinical appointment is a screening. During this screening, all participants were assessed by means of face-to-face conversations with a psychologist and self-administered questionnaires. Those who gave written informed consent, and where at least eighteen years of age are included in this study. Of the 220 MtFs, information about sexual orientation was available for 216 participants. The four MtFs who didn’t report their sexual orientation were excluded from this study. Considering FtMs, information on sexual orientation was available for all 129 applicants.
3.2 Operationalization and Procedure
The current study was part of the European Network for Investigation of Gender Incongruence (ENIGI). All data was collected during the diagnostic phase of the trajectory: before receiving GD diagnosis and before, if diagnosed, medical treatment. Both the Background Data Interview (BI) and the Body Image Scale (BIS) were handed out and filled in before the first appointment with the psychologist. Information on treatment wish was collected during a following appointment with a psychologist in training, and was gathered using a checklist provided by the clinic. The participant is asked whether he/she wants full treatment or partial treatment, and if yes, which treatments he/she would prefer. In case of preferring partial treatment, the motivation behind this choice is inquired.
3.3 Materials
3.3.1 Background Data Interview (BI)
Sexual satisfaction areas and sexual orientation were measured using the Background Data Interview (Verschoor & Poortinga, 1988; Doorn, Poortinga, & Verschoor, 1994; Kreukels et al., 2012). This is a questionnaire for the collection of background information used when diagnosing GD in adult individuals. A wide range of subjects are being questioned, such as biographical information, information on gender development, and clothing preferences. For this study we used information about the topics: ‘Sexuality’ and ‘Relationships’.
The following 6 questions were used to inquire about sexual satisfaction: “Do you masturbate?” (Yes, No), “How important is sex for you?” (Important, Not that important, Not important), “What is it like for you to have an orgasm?” (Always pleasant, Sometimes pleasant, Never pleasant, Not applicable), “Are you satisfied with your sex life?”(No, Yes), “Do you experience a pleasant sensation in your genitals when having sex?” (Yes, No, It depends, Not applicable), “Do you use your genitals when having sex?” (No, Yes, If yes: actively, passively, both). The following question, measured by the Kinsey Scale (Kinsey, Pomeroy, & Martin, 1949), was used for gathering information on sexual orientation: “To whom do you feel sexually attracted?” (Solely towards men, mainly towards men and sometimes towards women, mainly towards men but regularly towards women, towards men and women equally, mainly towards women but regularly towards men, mainly towards women and sometimes towards men, solely towards women, towards genderdysphoric individuals, not applicable). Participants who were completely or primarily attracted towards the gender they were assigned to at birth were classified as androphilic (MtF) and
gynephilic (FtM) individuals. Those who reported to be attracted to any of the other options were classified as non-androphilic (MtF) and non-gynephilic (FtM) individuals.
3.3.2 Body Image Scale (BIS)
Body satisfaction was measured using the Body Image Scale (BIS) for genderdysphoric individuals, developed by Lindgren and Pauly (1975). The BIS, with equivalent versions for MtFs consists of a list of 30 different body parts. It includes sex non-specific body parts such as: ‘nose’, ‘biceps’, and ‘voice’, and sex specific body parts such as: ‘Adam’s apple’, ‘penis-clitoris’, and ‘breasts’. This self-administered questionnaire asks to rate every characteristic using a five-point Likert-scale ranging from very satisfied (1) to very dissatisfied (5). The minimum score is 30 (satisfied) , and the maximum score is 180 (dissatisfied). The instrument was subjected to reliability tests, and the results proved the reproducibility of the scores (Lindgren & Pauly, 1975).
3.4 Data Analysis
Statistical analyses were conducted using IBM SPSS Statistics 20. Descriptive analyses were performed regarding assigned gender at birth and sexual orientation. Nonparametric tests such as chi-square (χ 2
) were used for calculating group differences on nominal data, such as the differences considering sexual satisfaction areas between the sexes and sexual Orientation group. Differences regarding body satisfaction (BIS scores) among the different subgroups were tested using independent sample t-tests. Correlations were measured using Pearson’s ‘r’. Effects of body satisfaction and sexual satisfaction areas on treatment wish have been conducted using logistic regression analyses.
4. Results
4.1 Sexual Orientation Among the Natal Sexes
As shown in Figure 1, of the Male-to-Females (N = 216) 33.6% reports to be androphilic, meaning that they are sexually attracted primarily towards men. 64.5% of MtFs reports to be non-androphilic, which means that MtFs are more often sexually attracted towards women, either sex, or genderdysphoric individuals. Among Female-to-Males (N = 128) 34.1% reports to be non-gynephilic, meaning that they are sexually attracted towards men, either sex, or genderdysphoric individuals. While 65.1% reports to be gynephilic, meaning that FtMs are more often attracted primarily towards women.
Figure 1. Sexual orientation among the sexes
4.2 Differences in Body Satisfaction
4.2.1 Differences Between the Sexes
As shown in Table 1 and 2, MtFs scored significantly higher than FtMs on the overall scores of the BIS scale (M = 102.49, SD = 17.69 versus M = 93.43, SD = 16.23), indicating higher body dissatisfaction: t(319) = 4.57, p < .001. Table 1 and 2 also present data on satisfaction with different body areas among MtFs. These analyses showed that MtFs were significantly less satisfied with the social & hair, head & neck, muscularity & posture and the genital region than FtMs. FtMs were significantly less satisfied with hip and chest region than MtFs.
4.2.2 Differences Considering Sexual Orientation
Considering overall BIS scores within the MtF group, androphilic individuals score lower, indicating that androphilic MtFs are more satisfied with their bodies than non-androphilic individuals (t(195) = 2.143, p < .05). Among MtFs both androphilic (M = 4.32, SD = 0.92) and non-androphilic (M = 4.43, SD = 0.83) individuals are the least satisfied with the genital region. The second least favorable body area is different for these groups. Androphilic individuals score second highest on the chest region (M = 3.91, SD = 0.69) while non-androphilic individuals score second highest on the social and hair area (M = 4.03, SD = 0.61). Looking closely at the difference considering body satisfaction between androphilic and non-androphilic individuals, it appears that areas that make the difference significant
are the social and hair, the head and neck, and hip region. Androphilic individuals are more satisfied with the social and hair area (t(194) = 3.21, p < .05), the head and neck region (t(195) = 2.200, p < .05) and the hip region (t(195) = 2.00, p < .05) than non-androphilic individuals.
Considering overall BIS scores within the FtM group, gynephilic individuals score lower than non-gynephilic individuals, indicating that non-gynephilic individuals are more satisfied with their bodies than gynephilic individuals (t(118) = 2.39, p < .05). Both gynephilic individuals and non-gynephilic individuals scored highest on the chest region (M = 4.20; M = 4.28), closely followed by the genital region (M = 4.18; M = 4.09) meaning that they are most dissatisfied with these regions. Gynephilic individuals are significantly more satisfied with the muscularity and posture area (t(118) = 2.52, p < .05) and the hip region (t(117) = 2.68, p < .05) than non-gynephilic individuals.
Table 1 Summery statistics of body Image Scores in Male-to-Females and Female-to-Males Considering Sexual Orientation
BIS
MtF FtM
Androphilic Non-androphilic Gynephilic Non-gynephilic
M (SD) M (SD) M (SD) M (SD)
Social and hair items 3.71 (0.75) 4.03 (0.61) 3.11 (0.63) 3.27 (0.55)
Appearance 3.34 (1.26) 3.92 (0.94) 3.09 (1.00) 3.35 (1.07) Body hair 4.43 (0.94) 4.32 (1.08) 3.28 (1.05) 3.49 (0.91) Body movement 2.74 (1.07) 3.39 (1.07) 2.76 (0.85) 2.93 (0.87) Facial hair 4.63 (0.821) 4.79 (0.49) 3.64 (1.20) 3.62 (0.94) Hair 3.08 (1.41) 3.37 (1.23) 2.09 (0.78) 2.19 (0.92) Voice 3.94 (1.14) 4.25 (0.88) 3.81 (1.11) 4.07 (0.86)
Head and neck region 3.13 (0.89) 3.40 (0.73) 2.43 (0.64) 2.66 (0.61)
Adam’s apple 3.74 (1.34) 3.80 (1.02) 3.07 (1.01) 3.31 (0.86)
Chin 3.03 (1.28) 3.18 (1.04) 2.21 (0.90) 2.49 (0.74)
Eye brows 2.81 (1.12) 3.25 (1.12) 2.22 (0.73) 2.45 (0.94)
Face 3.12 (1.13) 3.66 (0.92) 2.67 (1.04) 2.93 (1.09)
Nose 2.91 (1.35) 3.11 (1.13) 2.05 (0.82) 2.19 (0.77)
Muscularity and posture 2.93 (0.68) 3.01 (0.70) 2.70 (0.64) 3.00 (0.59)
Arms 2.52 (0.92) 2.78 (0.96) 2.50 (0.82) 2.95 (1.08) Feet 3.55 (1.13) 3.23 (1.13) 2.42 (0.83) 2.64 (0.85) Hands 2.87 (1.04) 2.97 (1.12) 2.40 (0.90) 2.54 (0.98) Height 2.64 (1.30) 2.70 (1.18) 2.81 (1.11) 3.29 (1.13) Legs/calves 2.55 (1.06) 3.73 (0.99) 2.28 (0.80) 2.58 (0.91) Muscles 3.06 (1.12) 3.11 (0.96) 3.22 (1.13) 3.52 (0.94) Shoulders 3.01 (1.23) 3.15 (1.10) 2.30 (1.01) 2.57 (1.02)
Upper arm muscles 3.31 (1.08) 3.21 (0.94) 3.34 (1.11) 3.60 (0.96)
Weight 2.94 (1.22) 3.05 (1.18) 2.99 (1.09) 3.21 (1.12) Hip region 3.05 (0.83) 3.29 (0.78) 3.42 (0.90) 3.83 (0.59) Bottom 3.14 (1.15) 3.22 (1.05) 3.25 (1.05) 3.58 (0.91) Figure 3.12 (1.13) 3.49 (1.12) 3.48 (1.06) 3.90 (0.82) Hips 3.00 (1.81) 3.47 (1.10) 3.58 (1.14) 4.21 (0.72) Thighs 2.77 (1.10) 2.95 (0.96) 3.45 (1.07) 3.95 (0.83) Waist 3.21 (1.17) 3.36 (1.05) 3.38 (1.11) 3.52 (1.04) Chest region 3.91 (0.69) 3.91 (0.89) 4.18 (0.58) 4.28 (0.62) Breast(s) 4.18 (1.03) 4.14 (1.10) 4.81 (0.40) 4.80 (0.41) Chest size 3.61 (0.98) 3.62 (1.00) 4.51 (1.03) 3.67 (1.09) Genital region 4.32 (0.92) 4.43 (0.83) 4.20 (0.88) 4.09 (0.74) Penis/clitoris 4.34 (0.96) 4.39 (0.90) 3.93 (1.12) 3.66 (1.02) Scrotum/vagina 4.30 (1.01) 4.47 (0.83) 4.32 (0.92) 4.26 (1.05) Testicles/ovary 4.39 (0.92) 4.46 (0.82) 4.34 (0.94) 4.37 (0.81) Overall mean 3.34 (0.60) 3.53 (0.56) 3.09 (0.54) 3.32 (0.44) Overall sum 98.51 (18.60) 104.45 (16.96) 90.94 (16.55) 98.88 (13.63)
Table 2 Differences in Body Image Scores
BIS
MtF FtM
Between androphilic & Between gynephilic & Between FtM & MtF
non-androphilic non-gynephilic
t(df)a t(df)a t(df)a
Social and hair items 3.21 (194)** 1.36 (118) 10.33 (318)***
Head and neck region 2.20 (195)* 1.89 (118) 10.08 (293)***
Muscularity and posture .70 (194) 2.51 (118)* 2.62 (319)**
Hip region 2.00 (195)* 3.02 (113)** -3.43 (318)** Chest region .02 (150) .82 (113) -69 (297)*** Genital region .79 (180) -.63 (111) 2.50 (296)* Overall mean 2.14 (195)* 2.39 (118)* 4.84 (319)*** Overall sum 2.24 (195)* 2.66 (118)** 4.67 (319)*** a * p < .05, ** p < .01, *** p < .001
4.3 Differences in Sexual Satisfaction Areas
4.3.1 Sexual Satisfaction Areas
In both MtFs and FtMs six different areas concerning sexual experience are being researched. These areas are the satisfaction with their sex life in general, the importance of sex, masturbation, pleasure of orgasm, genital pleasure, and genital use (when having sex) (figure 2). The majority of both MtFs and FtMs are dissatisfied with their sex lives in general (66.2% and 59.8%), while a minority find their sex lives unimportant (15.2% and 16.3%). Of both MtFs and FtMs most individuals masturbate (73.8% and 63.6%). Among FtMs 3.1% and 12.7% of the MtFs never experience pleasure when having an orgasm. Most of both MtFs and FtMs don’t experience genital pleasure, but do use their genitals when having sex.
Figure 2. Questionnaire item responses of Sexual satisfaction, Genital use, Masturbation, Importance of sex, Genital pleasure and the Pleasure of orgasm among MtFs and FtMs
0% 20% 40% 60% 80% 100% MtFs FtMs Sexual Satisfaction
Yes No Missing answer
0% 20% 40% 60% 80% 100% MtFs FtMs Masturbation
Yes No Missing answer
0% 20% 40% 60% 80% 100% MtFs FtMs Genital Use
Yes No Missing answer
0% 20% 40% 60% 80% 100% MtF FtM Importance of Sex
Missing answer Not important Not that important Important
0% 20% 40% 60% 80% 100% MtF FtM Genital Pleasure
Missing answer Sometimes
No Yes 0% 50% 100% MtF FtM Pleasure of Orgasm
Missing answer Never Sometimes Always
4.3.2 Differences considering Sexual Satisfaction Areas between the Sexes and Sexual Orientation groups
Significant differences in sexual satisfaction areas between MtFs and FtMs were found. MtFs are more likely to use their genitals when having sex in comparison to FtMs (χ2(1, N = 226) = 3.996, p < .05). FtMs are more likely than MtFs to experience pleasure when having an orgasm (χ2(2, N = 281) = 10.896, p < .01). Considering other sexual satisfaction areas researched, no significant differences between MtFs and FtMs were found (see Appendix: A).
Among MtFs significant differences were found between androphilic and non-androphilic individuals concerning different aspects of sexual satisfaction. Androphilic MtFs are less likely to use their genitals than non-androphilic MtFs (t(140) = 3.142, p < .05), and androphilic MtFs find sex more important than non-androphilic MtFs (t(209) = -2.212, p < .05). Regarding sexual satisfaction in general, no significant differences were found between androphilic and non-androphilic MtFs. In FtMs there was also a significant difference found between gynephilic and non-gynephilic individuals concerning sexual experience. Gynephilic FtMs find their sex lives more important than non-gynephilic FtMs (t(126) = -3.452, p = .001). Regarding satisfaction with their sex lives in general, no significant differences were found between gynephilic and non-gynephilic FtMs.
In both MtFs and FtMs no significant correlations were found between the specific sexual experience items and sexual satisfaction in general. The pleasure of orgasm on the other hand correlates particularly high with all the other sexual experience items. In MtFs the pleasure of orgasm correlates positively with masturbation (r = .188, n = 179, p < .05), the importance of sex (r = .311, n = 179, p < .001), genital use when having sex (r = .194, n = 124, p < .05) and genital pleasure (r = .207, n = 147, p < .05). In FtMs the pleasure of orgasm is positively correlated with masturbation (r = .348, n = 93, p = .001), the importance of sex (r = .257, n = 98, p < .05), genital use (r = .348, n = 69, p < .05) and genital pleasure (r = .390, n = 74, p = .001) as well.
4.4 Correlations Between Body Satisfaction and Body Satisfaction Areas and Sexual Satisfaction Areas
4.4.1 Correlations Between Body Satisfaction and Sexual Satisfaction Areas
In FtMs a negative correlation was found between body satisfaction overall and the pleasure of orgasm (r = -.282, n = 90, p < .05). This indicates that in FtMs lower body satisfaction in general is associated with less pleasure of orgasm. No correlations were found between body satisfaction and sexual satisfaction in general, the importance of sex, the use of the genitals, masturbation, and the appraisal of the genitals in FtMs.
In MtFs a negative correlation was found between body satisfaction and sexual satisfaction in general (r = -.198, n = 180, p < .05), indicating that lower body satisfaction is associated with lower sexual satisfaction. Another negative correlation was found between body satisfaction and whether MtFs consider their sex lives to be important (r = -.149, n = 194, p < .05). Higher body satisfaction is associated with finding their sex lives more important. Considering the pleasure of orgasm, the use of the genitals, masturbation, and the appraisal of the genitals when having sex, no correlations were found with body satisfaction in MtFs.
4.4.2 Correlations Between Body Satisfaction Areas and Sexual Satisfaction Areas
Concerning different body areas there were correlations found with sexual experience items in both MtFs and FtMs.
In MtFs genital body satisfaction correlates with all examined aspects of sexual satisfaction researched in this study. Correlations were found regarding masturbation (r = -.168, n = 178, p < .05), the importance of sex (r = -.369, n = 179, p < .001), pleasure of orgasm (r = -.356, n = 153, p < .001), genital pleasure when having sex (r = -.166, n = 139, p = .05), and the use of their genitals when having sex (r = -.235, n = 123, p < .05). In general, genital body satisfaction is correlated with sexual satisfaction (r = -.172, n = 165, p < .05). This indicates that the less satisfied MtFs are with their genitals, the less satisfied they are with their sex lives. Concerning the satisfaction of two more body areas a correlation has been found with sexual satisfaction. An association between sexual satisfaction and satisfaction with the head and neck region (r = -.200, n = 181, p < .05) and the hip region (r = -.155, n = 180, p < .05) indicate that the less satisfied MtFs are with these regions the less satisfied they are with their sex lives.
In FtMs no correlations were found between genital body satisfaction and the importance of sex, genital pleasure and sexual satisfaction. Genital body satisfaction is associated with masturbation (r = -.323, n = 108, p = .001), the pleasure of orgasm (r = -.310, n = 85, p < .05) and the use of their genitals when having sex (r = -.384, n = 72, p = .001). This indicates that in FtMs genital body satisfaction is associated with sexual aspects concerning the genitals but not with sexual satisfaction in general. FtMs are, apart from the genital area, the least satisfied with the chest area. Considering the different aspects of their sex lives, no correlations were found with the satisfaction of their chest area.
Table 4. Correlations Body Image Areas and Sexual Experience
Sexual Masturbation Importance Pleasure Genital Genital
Satisfaction of Sex of Orgasm Pleasure Use
MtF FtM MtF FtM MtF FtM MtF FtM MtF FtM MtF FtM
Pearson Correlation (N)a
BIS -.198(180)** -.164(114) .079(192) -.113(114) -.147(194)** -.084(121) -.147(165)* -.282(90)** -.013(152) -.093(80) .059(132) -.069(76)
Social & Hair -.129(180) -.094(114) .115(191) -.076(114) -.104(192) -.016(121 -.049(164) -.247(90)* -.012(150) -.052(80) .157(132) -.024(77)
Head & Neck -.200(181)** -.192(114)* .049(192) -.044(114) -.147(194)* -.088(121) -.052(165) -.176(90) -.031(152) 0.37(80) .041(132) .002(76)
Muscularity & Posture -.135(178) -.174(114) .052(192) -.086(114) -.061(193) -.071(121) -.114(165) -.226(90)* -.037(151) -.094(80) .015(131) -.004(76) Hip region -.155(180)* -.086(113) .097(192) .050(114) -.054(194) -.032(120) -.040(165) -.159(89) .091(153) -.203(80) .123(132) .068(75) Chest Region -.110(171) -.163(109) .126(183) -.175(109) .015(184) .024(116) -.077(158) -.155(86) .007(143) -.122(77) .051(126) -.024(73) Genital Region -.172(165)* -.038(107) -.168(178)* -.323(108)** -.369(179)*** -.150(114) -.356(153)*** -.310(85)** -.166(139) -.126(75) -.235(123)*** -.384(72)** a * p < .05, ** p < .01, *** p < .001
4.5 The Effect of Body Satisfaction Areas and Sexual Satisfaction Areas on Treatment Wish
Direct logistic regression was performed to assess the impact of the following predictors: all 6 of the body satisfaction areas, sexual satisfaction in general and the pleasure of orgasm on whether participants wish a full or a partial treatment. A statistically significant effect was found, χ2(9, N = 164) = 61.398, p < .001, indicating that the model was able to distinguish between participants who wished a full treatment and those who wished partial treatment. The model explained between 31.2% (Cox and Snell R square) and 42.8% (Nagelkerke R squared) of the variance in treatment wish, and correctly classified 76.8% of all cases (figure 3). Of the different predictors included, only satisfaction of the hip region (B = .843, p < .05), chest area (B = .829, p < .05) and genital region (B = -1.422, p < .001) appeared to be significant predictors for treatment wish. This indicates that participants who are less satisfied with the hip region and chest area are more likely to wish partial treatment and the less satisfied participants were with the genital area, the more likely they were to choose a full treatment over a partial treatment.
When examining MtFs and FtMs separately no significant effect of body satisfaction on treatment wish was found.
5. Discussion
The first aim of this study was to explore the relations between body satisfaction, sexual satisfaction, and treatment wish in transgender adults applying for gender confirming interventions (GCIs). In order to create and facilitate the best fitting care for every genderdysphoric individual, it’s crucial that the treatment wishes and the underlying motives for choosing any kind of treatment are examined. The second aim of this study was to explore variety among transgender individuals. Variety was explored concerning sex: male-to-females (MtFs) and female-to-males (FtMs), and differences between these groups were expected. The sample consisted for about two thirds of MtFs and for about one third of FtMs. Differences among MtFs were researched between androphilic and non-androphilic individuals, and within the FtM group between gynephilic and non-gynephilic individuals. Just as previous research appoints (Auer, Fuss, Höhne, Stalla, & Sievers, 2014; Simonsen, Hald, Giraldi, & Kristensen, 2015) the larger part of MtFs identifies as non-androphilic, and the larger part of FtMs identifies as gynephilic. The current research showed that body satisfaction and sexual satisfaction were moderately correlated, where in particular satisfaction with the genital area cohered with sexual satisfaction. Differences between the natal sexes were found considering both body satisfaction and sexual satisfaction. Body satisfaction and sexual satisfaction were able to predict treatment wish of genderdysphoric individuals applying for GCIs.
Replicating prior findings (Cerwenka, et al. 2014), MtFs reported higher body dissatisfaction than FtMs. There are several possible explanations for this difference. First, sexualization of the female body might lead to higher ‘standards’ that MtFs want to meet when transitioning their bodies. Second, femininity in males is less socially accepted than masculinity in females. This can mean that the transition is more extensive: going from ‘male’ clothing to ‘female’ clothing. While ‘male’ clothing for females is more accepted, leading to a less extensive change in physical appearance. A third reason for this difference could be that the MtFs who apply for GCIs are just starting, or haven’t started a social transition to the opposite gender. Living as the preferred gender may result in a more positive body satisfaction, so it could be that the FtMs who were included in this study were ‘further’ in their social transition. Different degrees in social transitioning weren’t inquired and thus, are not included in this study. A fourth factor that could contribute to this difference is age. If MtFs are indeed facing more stigma during their developmental pathway of transitioning into their true self, that could result in living as their assigned gender for a longer period of time before applying for a GCI, in comparison to FtMs. Previous research shows that FtMs seek treatment earlier than MtFs (Simonsen, Hald, Giraldi, & Kristensen, 2015). The distress that accompanies living as the assigned gender could manufacture higher levels of dissatisfaction with the body. Age wasn’t included in this study, but might therefore be informative when exploring body satisfaction in people with GD.
Body satisfaction concerning different body areas was also investigated, and again differences were found between MtFs and FtMs. MtFs were less satisfied in general and so it was to be expected that MtFs were also less satisfied concerning the different body areas. MtFs were the least satisfied with the genital area, yet for FtMs dissatisfaction was lowest with both the genital and the chest area. As expected, FtMs reported higher dissatisfaction with the chest area than MtFs did. Previous research by Beek, et al. (2015) showed that FtMs were more likely to prefer partial treatment than MtFs, and that the most reported reason for FtMs to choose partial treatment over a full treatment was their concerns about surgical risks of genital surgery or disappointing outcome. Besides more frequently occurring surgical problems for FtMs in comparison to MtFs, because of the complexity of the intervention (Beek, et al. 2015), it could be that the actual underlying motive for choosing a
experience seem to result from social situations where characteristics of their appearance that belong to the assigned gender could easily be noticed by other people. In MtFs this would lead to dissatisfaction with social and hair region; such as having a low voice and having facial hair, and MtFs did report to be the least satisfied with, besides the genital area, the social and hair region.
Considering sexual satisfaction among genderdysphoric individuals previous research finds various differences between natal males and natal females. FtMs were found to report experiencing more pleasure than MtFs when having an orgasm (Cerwenka, et al. 2014), a result that was also found in the current study. Cerwenka, et al (2012) pointed at the fact that MtFs more often reported that they never experienced pleasure when having an orgasm, opposed to FtMs who more often reported that the question was ‘not applicable’. A possible reason for this difference could be that MtFs use their genitals more often than FtMs, and so MtFs would be having more orgasms than FtMs. The current study does show that MtFs use their genitals more often. Which stands out, because MtFs also report more dissatisfaction with the genital area in comparison to FtMs. It may be that, having an orgasm can lead to genital dissatisfaction in both MtFs and FtMs, and because MtFs use their genitals more, they experience more orgasms, therefore are less satisfied than FtMs. Another underlying reason for this could be that in natal men sexual arousal and orgasm are more closely linked than in natal women. Yet the frequency of having an orgasm wasn’t measured. The masculinity of the male erection as well as the male ejaculation could contribute to the dissatisfaction MtFs experience. Future research on sexual satisfaction should include specifics considering sexual experiences. Especially in research considering sensitive subjects such as sexuality, clear questions, preferably asked in an interview instead of a questionnaire, could contribute valuable information.
To explore differences in the GD population that could concern both sexual satisfaction and body satisfaction, differences among the different sexual orientation groups were researched. No significant differences were found in previous research among MtFs and FtMs. In the current research differences among both MtFs and FtMs were found, considering both body satisfaction and sexual satisfaction. Androphilic MtFs appeared to be more satisfied with their bodies than non-androphilic MtFs. When comparing satisfaction with different body areas, non-androphilic MtFs report to be more satisfied with the social and hair region, head and neck region and with the hip region. These regions concern the more ‘visible’ body areas in social encounters. A difference between androphilic and non-androphilic individuals might be that before they are socially transitioned into the preferred gender, non-androphilic individuals have, expectedly, heterosexual experiences and desires. While androphilic individuals have homosexual experiences and desires. Being a feminine homosexual male is more socially accepted, within the homosexual community at least, than being a feminine heterosexual male. Previous research found that androphilic MtFs have a physical appearance more congruent with their desired gender, in comparison to non-androphilic MtFs (Van de Grift, et al. 2016b), meaning that they have a more feminine physique. This may lead to more acceptance of the body in androphilic individuals, in particular considering those parts that are notable in a social context. Within the genderdypshoric population stigmatization can exist, and can lead to distress when individuals don’t act like the ‘average’ person with GD. It firstly seems more expected that MtFs are romantically interested in men, and so it may be easier to come out as genderdysphoric in comparison to non-androphilic individuals who don’t fit these ‘standard’ criteria. Secondly, androphilic MtFs probably have already endured a period of self-acceptance and sharing their sexual orientation with others, while non-androphilic individuals, especially those who’ve had or are currently in romantic relationships with women, have not. This is comparable with the possible reason why FtMs are more satisfied with their bodies; because they might be further in their social transitioning. This may result in a more advanced state of acceptance about the self and the own body.
Among FtMs similar results have been found, where gynephilic individuals are generally more satisfied with their bodies than non-gynephilic individuals. However, this discrepancy may also result from a rather small group of non-gynephilic individuals that was included in this study. Little information is known about non-gynephilic individuals as a separate group, and future research should focus on the way sexual orientation can influence body satisfaction in these individuals.
Among the sexual satisfaction areas that were researched, the pleasure of orgasm stands out as a central factor because of correlating with the other sexual satisfaction areas researched. In previous research among cisgender individuals, orgasm appears to be closely linked to sexual satisfaction (Haning, et al. 2007; Philippsohn & Hartmann, 2009). The pleasure of orgasm does include both an ‘emotional-experience’ feature and a ‘frequency-experience’ feature, while the other areas focus on one or the other. This may lead to coherence among the pleasure of orgasm and the other sexual satisfaction areas.
Considering the relation between sexual satisfaction and body satisfaction for as far as we know, no previous research was conducted. The current study shows moderate correlations between the different areas. Considering body satisfaction areas, genital body satisfaction in particular is associated with sexual satisfaction. People who are less satisfied with their genital area also report dissatisfaction with their sex lives. FtMs are dissatisfied primarily, besides with their genital area, with their chest area. Yet, satisfaction with the chest area is not found to be associated with sexual satisfaction in both MtFs and FtMs. As mentioned earlier, previous research in cisgender people found that women’s sexual satisfaction is not related to body satisfaction, or at least not considering satisfaction with social appearance. People with GD who are sexually less satisfied do show more dissatisfaction with their bodies, however, this not necessarily includes satisfaction with socially related body parts that are visible when, for example, meeting new people. Body satisfaction and sexual satisfaction therefore seem two separate constructs with overlapping components.
Differences among the GD population occur according to sex, sexual orientation and cover body satisfaction, sexual satisfaction, and different desires for treatment wish. Body satisfaction and sexual satisfaction were found useful when trying to predict which GCIs genderdysphoric individuals’ desire. However, only the satisfaction with three different body areas were found to be significant predictors. It seems, however, that because of differences between MtFs and FtMs concerning both body satisfaction and sexual satisfaction it would be better to study these factors as predictors for treatment wish distinctively. The current study shows that body satisfaction and sexual satisfaction can’t predict treatment wish when studying MtFs and FtMs separately, but this might be due to the small samples. It may be that, when researching a larger sample, body satisfaction and sexual satisfaction in MtFs appear better at predicting treatment wish than in FtMs. There may be other factors influencing wishing a particular treatment, such as feeling more dysphoria concerning the chest area in comparison to the genital area and because of sexual satisfaction being less related to body satisfaction in FtMs, it seems that for FtMs the dysphoria might be a more decentralized construct in comparison to MtFs. While in MtFs GD seems to be more centralized around genital dysphoria.
In conclusion, the current study focused on both hypotheses that replicated previous research and on hypotheses that hadn’t been studied thus far. As previous research found, of both MtFs and FtMs the larger part of the group were sexually orientated towards females. In MtFs this meant that most individuals were non-androphilic, opposed to androphilic, while in FtMs most individuals were gynephilic, opposed to non-gynephilic. Concerning body satisfaction, MtFs showed more dissatisfaction than FtMs did. MtFs were the least satisfied with their genital area, followed by the ‘social and hair’ region, which includes facial features. FtMs where the least satisfied with their
FtMs, and non-androphilic MtFs. Concerning sexual satisfaction in both groups, FtMs reported experiencing more pleasure when having an orgasm than MtFs did. Previous research also found that MtFs use their genitals more (Selvaggi, et al. 2007; Coleman, et al. 1993; Kraemer, et al. 2010, cited by Cerwenka, et al. 2014), when having sex with another person, which was also found in the present study. The present study was, as far as we know, the first to focus on the cohesion between body satisfaction and sexual satisfaction. Moderate correlations between body satisfaction and sexual satisfaction among adult transgender individuals were found. This was primarily apparent considering satisfaction with the genitals and sexual satisfaction. The present study also appointed the importance of the pleasure of orgasm when examining sexual satisfaction in individuals with GD. Mainly because of the correlations between the pleasure of orgasm and other sexual satisfaction areas that were examined. Body satisfaction and sexual satisfaction combined were good predictors for whether genderdysphoric individuals would choose a partial or a full treatment. The presents study underlines the variation among transgender individuals, the cohesion between body satisfaction and sexual satisfaction and the importance of body satisfaction and sexual satisfaction in the wish for a particular treatment. When providing the best fitting care for individuals with GD these differences and these factors that can influence an individual’s wish should therefore be a main focus.
6. Limitations
The current study focused on body satisfaction, sexual satisfaction, and treatment wish among genderdysphoric individuals. A possible limitation of the present analyses was that the non-gynephilic FtM group was much smaller than the other groups, leading to less informative values when examining differences between the sexual orientation groups. When comparing the different groups a larger sample would lead to larger sexual orientation groups, and would therefore be recommended. Both body satisfaction and treatment wish were collected using a questionnaire. Using a self-report method when collecting information on sensitive topics has both beneficial and negative aspects. Firstly, every participant received the same questionnaire, and the same short introduction, which precludes biases that can lead to . The diagnostic phase after applying for GCIs, during which the present study was performed, covers a wide variety of research concerning many aspects of life, which is time consuming and can be very overwhelming and intense for the participant. So, secondly, using questionnaires is faster and has a more ‘private’ way of inquiring sensitive information in comparison to, for example, an interview.
However, self-reported experiences also have several shortcomings, of which one in particular might be of influence when conducting this research. Before being able to start with medical treatment, every participant must receive a GD diagnosis. A study by Linander, Alm, Hammerstrom & Harryson (2017) reports that people applying for medical treatment in western countries experience distress following long waiting times, lack of support, provider ignorance, and relationships of dependency between them and their caretakers. Anticipating on these possible difficulties, people who apply might feel like they must fulfill all the exact criteria of GD in order to receive better care. This may lead to a social desirability bias influencing the results of the current study.
Treatment wishes were collected during a subsequent appointment with different practitioners. The information on treatment wish was asked using a set of questions, but was mainly interpreted by these practitioners who were both different for every participant, and were not the permanent psychologist caring for the participant. This may have led to an interviewer bias, and could have led to altering results. Information on treatment wish might be more reliable when it is inquired by the same practitioner as the rest of the research is. Future research should use a combination of both interviews and questionnaires but can prevent rater bias by letting one interviewer do the interpretations.
7. References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: APA.
Auer, M. K., Fuss, J., Höhne, N., Stalla, G., K., & Sievers, C. (2014). Transgender Transitioning and Change of Self-Reported Sexual Orientation.PLoS ONE 9(10): e110016.
Becker, I. Nieder, T. O., Cerwenka, S., Briken, P., Kreukels, B. P., Cohen-Kettenis, P. T., et al (2016) Body Image in Young Gender Dysphoric Adults: A European Multi-Center Study. Archives of
Sexual Behavior, 45, 559-574.
Beek, T. F., Kreukels, B. P., Cohen-Kettenis, P. T., and Steensma, T. D. (2015). Partial Treatment Requests and Underlying Motives of Applicants for Gender Affirming Interventions. The
Journal of Sexual Medicine, 12(11), 2201-2205.
Cash, T. F. (2004) Body image: past, present, and future. Body Image, 1, 1-5.
Cerwenka, S., Nieder, T. O., Cohen-Kettenis, P., De Cuypere, G., Hebold Haraldsen, I. R., Kreukels, B. P., Richter-Appelt, H. (2014). Sexual Behavior of Gender-Dysphoric Individuals Before Gender-Confirming Interventions; A European Multicenter Study. Journal of Sex & Marital
Therapy, 40(5), 457-471.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., De Cuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13 (4), 165-232. De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., and
Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics, 134, 696-704.
Doorn, C. D., Poortinga, J., and Verschoor, A. M. (1994). Cross-Gender Identity in Transvestites and Male Transsexuals. Archives of Sexual Behavior, 23(2), 185-201.
Fink, B., Klappauf, D., Brewer, G., & Shackelford, T. (2014). Female Physical Characteristics and Intra-Sexual Competition in Women. Personality and Individual Differences, 58, 138-141. Fiske, L., Fallon, E. A., Blissmer, B., & Redding, C. A. (2014). Prevalence of body dissatisfaction
among United States adults: Review and recommendations for future research. Eating
behaviors, 15, 357-365.
Gijs, L. & Brewaeys, A. (2007). Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges. Annual Review of Sex Research, 18(1), 178-224.
Gooren, L. J. (2011). Care of Transsexual Persons. The New England Journal of Medicine. 365, 1251-1257.
Haning, R. V., O’Keefe, S. L., Randall, E. J., Kommor, M. J., Baker, E., & Wilson, R. (2007). Intimacy, Orgasm Likelihood, and Conflict Predict Sexual Satisfaction in Heterosexual Male and Female Respondents. Journal of Sex and Marital Therapy, 33(2), 93-113.
Kinsey, A. C., Pomeroy, W. R., & Martin, C. E. (1948). Sexual Behavior in the Human Male. Philadelphia, PA: Saunders.
Kreukels, B. P., Haraldsen, I. R., De Cuypere, G., Richter-Appelt, H., Gijs, L., & Cohen-Kettenis, P. T. (2012). A European network for the investigation of gender incongruence: The ENIGI initiative. European Psychiatry, 27, 445-450.
Lindgren, T. W., and Pauly, I. B. (1975). A Body Image Scale for Evaluating Transsexuals. Archives
of Sexual Behavior, 4(6), 639-656.
Lawrence, A. A. (2009). Sexual Orientation versus Age of Onset as Bases for Typologies (Subtypes) for Gender Identity Disorder in Adolescents and Adults. Archives of Sexual Behavior, 39, 514-545.
Milhausen, R. R., Buchholz, A. C., Opperman, E. A, & Benson, L. E. (2015). Relationships Between Body Image, Body Composition, Sexual Functioning, and Sexual Satisfaction Among Heterosexual Young Adults. Archives of Sexual Behavior, 44, 1621-1633.
Phlippsohn, S. & Hartmann, U. (2009). Determinants of Sexual Satisfaction in a Sample of German Women. The Journal of Sexual Medicine, 6, 1001-1010.
Prantl, L. & Gründl, M. (2011). Males Prefer a Larger Bust Size in Women Than Females Themselves: An Experimental Study on Female Bodily Attractiveness with Varying Weight, Bust Size, Waist Width, Hip Width, and Leg Length Independently. Aesthetic Plastic Surgery.
35(5), 693-702.
Redfern, J. S., & Sinclair, B. (2014). Improving Health Care Encounters and Communication with Transgender Patients. Journal of Communication in Health Care. 7(1), 25-40.
Simonsen, R., Hald, G. M., Giraldi, A., & Kristensen, E. (2015). Sociodemographic Study of Danish Individuals Diagnosed with Transsexualism. Sexual Medicine, 3, 109-117.
Van der Grift, T. C., Cohen-Kettenis, P. T., Elaut, E., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., & Kreukels, B. P. (2016a). A Network Analysis of Body Satisfaction of People with Gender Dysphoria, Body Image, 17, 184-190.
Van de Grift, T. C., Cohen-Kettenis, P. T., Steensma, T. D, De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., et al. (2016b). Body Satisfaction and Physical Appearance in Gender Dysphoria. Archives of Sexual Behavior, 45, 575-585.
Verschoor, A. M., and Poortinga, J. (1988). Psychosocial differences between Dutch male and female transsexuals. Archives of Sexual Behavior, 17, 173-178.
Woertman, L., and Van den Brink, F. (2012) Body Image and Female Sexual Functioning and Behavior: A Review. The Journal of Sex Research, 49(2-3), 184-211
The World Professional Association for Transgender Health (WPATH) (2011). Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People.
8. Appendices
8.1 Appendix A: Frequencies and Differences among MtFs and FtMs concerning Sexual Experience
Frequencies and Differences among MtFs and FtMs concerning Sexual Experience
MtF FtM MtF-FtM Freq. (%) Freq. (%) X2(df)a Sexually satisfied No 129 (58.6) 73 (56.6) 1.296 (1) Yes 66 (30) 49 (38) Missing answer 25 (11.4) 7 (5.4) Genital pleasure No 75 (34.1) 37 (28.7) .133 (2) Sometimes 61 (27.7) 32 (24.8) Yes 34 (15.5) 18 (14.7) Missing answer 50 (22.7) 41 (31.8) Genital use No 48 (21.8) 39 (30.2) 3.996 (1)* Yes 95 (43.2) 44 (34.1) Missing answer 77 (35) 46 (35.7) Masturbation No 55 (25) 44 (34.1) 3.790 (1) Yes 155 (70.5) 77 (59.8) Missing answer 10 (4.5) 8 (6.2)
Importance of sex Not important 32 (14.5) 21 (16.3) 1.833 (2)
Not that important 112 (50.9) 59 (45.7)
Important 67 (30.5) 49 (38)
Missing answer 9 (4.1) 0 (0)
Pleasure of orgasm Never 28 (12.7) 4 (3.1) 10.895 (2)**
Sometimes 96 (43.6) 48 (37.2)
Always 59 (26.8) 46 (35.7)
Missing 37 (16.8) 31 (24)
