Evaluating psychobiological and mental distress in transsexualism before and after cross-sex hormonal treatment: Lesson learned from three longitudinal studies

In the past few decades, the literature has addressed transsexual patients' quality of life, satisfaction and various other outcomes such as sexual functioning after sex reassignment surgery. Instead, the role of the cross-sex hormonal treatment alone in the well-being of transsexual patients has been the subject of very little differentiated investigation. Moreover, due to their cross-sectional design, previous studies did not demonstrate a direct effect of hormonal treatment in transsexual patients' distress. To our knowledge only three recent researches studied the transsexual patients' distress related to the hormonal treatment in a longitudinal study. In light of the importance of this information, this chapter discusses a review of these three perspective studies, two of whom were performed in partially overlapping samples from the same gender unit. Although transsexualism has been described as a diagnostic entity in its own right, not necessarily associated with severe comorbid psychiatric findings, for most patients transsexualism may be a stressful situation and may cause clinical distress or impairment in important areas of functioning. This review provides information on the prevalence and/or severity of psychobiological distress, mental distress and functional impairment in untreated transsexual patients. One of these three studies revealed that, despite the majority of transsexual patients do not suffer of a psychiatric disorder, the condition is associated with subthreshold anxiety/depression, psychological distress and functional impairment. Another of these three studies achieved the same results on the psychological distress in untreated transsexual patients, using part of the methodology of the previous study in a different sample. The last study added information about the untreated transsexual patients' stress system dysregulation, revealing that these patients show hypothalamic-pituitary-adrenal (HPA) system dysregulation and appear to notably differ from normative samples in terms of mean levels of perceived stress. In particular, untreated transsexual patients showed elevated cortisol awakening response (CAR), with cortisol levels above the normal range, and elevated perceived stress. Moreover, this review reports the role of the hormonal treatment in reducing psychobiological and mental distress in transsexualism. Specifically, when treated with hormonal treatment transsexual patients reported less anxiety, depression, psychological distress and functional impairment. Also transsexual patients showed reduced cortisol awakening response (CAR) and perceived stress levels after the beginning of the cross-sex hormonal treatment. It should be added that in all the three studies the psychobiological and mental distress scores resembled those of a general population after cross-sex hormonal treatment was initiated. Finally, the review discusses the hypothesis of a direct relation versus an indirect relation between the hormone therapy itself and the patients' wellbeing, supporting a psycho-social meaning of the hormonal treatment (indirect relation) rather than a biological effect of sex hormones (direct relation).