May 012013

One way to reduce stress and cortisol - CC BY 2.0 - flickr user eamoncurry123Summary: Research now indicates that cross-sex hormone therapy is associated with a lower cortisol awakening response in trans people, regardless of attachment style. Many confounding variables, however, were present in this study.

Transgender people have long asserted that gender dysphoria can be extremely distressing and that transition, including hormone therapy, helps relieve that dysphoria. Hormone therapy is known to improve self-reported quality of life, as measured by questionnaire. To my knowledge no other study has looked at stress-related biological factors in trans people. Biological factors are important because self-report is notorious for validity problems. This study looked at one such biological factor, called the cortisol awakening response.

What is the cortisol awakening response? Readers of the blog may remember the last time I spoke about cortisol (paragraph #2). For those who don’t remember…. cortisol is a “stress hormone.” When we’re stressed, whether by speaking in public or running from a lion, cortisol is released. It helps our body be ready for immediate survival by increasing blood sugar and helping with metabolism. High cortisol levels over a long period of time can have many negative effects on health, including weakening the immune system. The cortisol awakening response is part of the daily cycle, when blood levels spike about 20-30 minutes after waking in the morning. The cortisol awakening response is larger in stressed people than in non-stressed people and can be affected by many things, including burn out, fatigue, aspirin, and sleep schedule. Awakening response is thought to be a good indicator of general stress levels and as a good indicator for stress-related disease risks.

Participants in this study were 70 trans people seen at the Gender Identity Unit of the University of Bari Psychiatric Department, roughly 64% trans women. All the participants had the same hormonal treatment; transdermal estradiol gel and cyproterone acetate (an anti-androgen) for trans women, intramuscular testosterone esters for trans men. They were assessed before hormone therapy and 12 months after starting hormone therapy. There was no significant difference in age, education, or occupation between the two groups.

The researchers measured perceived stress (a self-report of how stressed a person feels) in addition to the cortisol awakening response. The cortisol awakening response was measured by a blood test at 8:00am on three consecutive days, 1 hour after waking.

The results were striking. Before treatment, both perceived stress and cortisol levels were above the  “normal” range. After twelve months of hormone therapy, both were much lower and back within normal ranges. There were no statistically significant differences between trans men and trans women.

However there are a number of confounds for this study. Cortisol levels vary with sex hormones. For example, the cortisol levels of menstrual women will vary depending on which part of the menstrual cycle they’re in. Could cross-sex hormone therapy have caused this change in cortisol levels? Maybe, but then I’d expect there to be a difference between the trans men and trans women in this study and there weren’t.

The researchers also did not appear to attempt to control for other factors which could have impacted the cortisol awakening response. Changes in sleep patterns (e.g., naps) or sleep quality (e.g., a noisy environment) have effects on the cortisol awakening response. As far as I can tell the researchers did not screen for these changes.

Cortisol and stress were not the only things measured in this study. The researchers also looked at attachment styles. Attachment styles are a psychological concept. The idea is that when we are children our interactions with parents, and how they respond to our needs, affects the type of “attachment” we have. Attachment styles are secure or insecure. A secure attachment often results in happy adult relationships. Insecure attachments include avoidant, anxious, and unresolved/disorganized styles. Attachment styles may influence how we respond to stress, so they could have been a confound in this study if not examined.

The researchers determined the attachment style of the participants with a structured interview. They found that trans people are more likely to have an insecure attachment (70%) than the general population with no psychiatric diagnoses (44%). Attachment style did not, however, appear to be correlated with cortisol awakening response or perceived stress.

In other words, the relationship trans people have with their parents did not appear to affect the stress-reducing effects of hormone therapy.

I do not really understand why these researchers chose to examine attachment style in this study. I think that knowing attachment styles may be useful for therapy or for the development of effective variations on therapies for trans people. But I don’t feel that the inclusion of attachment style was sufficiently justified in this study. Why look at attachment and not, for example, socioeconomic status or social support? I would think either of those would be more likely to have an impact on stress levels than attachment.

On the whole: I think that the cortisol results of this study are decent validation of the anecdotal evidence from trans people themselves, but that the exploration of attachment style in this context is a red herring.

The abstract is publicly available.

Mar 012012

It’s fairly well known that sexual reassignment surgery is associated with an increase in quality of life for transsexual people. Or, in other words, that transsexual people are happier after surgery than before surgery. OMH reviewed one such study specific to transsexual men. Studies so far have not examined another major component of medical transition: hormone therapy (HRT). Does HRT also improve quality of life? Finally, a study has been published which examines HRT and quality of life in transsexual people.

This new study looked at a group of pre-transition transsexual men and women. It compared their quality of life before and after starting HRT. They found that quality of life improved with HRT.

They also compared the quality of life of transsexual people with that of cissexual (i.e., not transsexual) people of the same age and sex. In that comparison they largely found that there was no difference in quality of life between transsexual and cissexual people… with two exceptions. Transsexual people had more problems than cissexual people with daily activities because of their physical health. On the other hand, cissexual people thought their health was poorer than transsexual people did.

One caveat, however: The results of this study may not be applicable to the entire transgender community. For example, this study specifically only looked at transsexual people who were over 18. HRT may or may not increase quality of life for transsexual people who are under the age of 18. This study also only included transsexual people who met the diagnostic criteria for Gender Identity Disorder in the Diagnostic and Statistical Manual IV-TR. It’s also worth noting that those criteria are changing with the DSM-V, and that there is a healthy debate over it. Additionally, this study was conducted in France. The results may be specific to France (or Europe, or the Western world). The experience of transsexual people from other areas may be different.

When I mentioned this study to a friend of mine, she looked at me and said, “Well…. duh.” She has a point — this research does seem obvious. Unfortunately we often stray when we base our decisions on anecdotal evidence. It’s always good to know that what seems like common sense really is sensical.

This study was published in the Journal of Sexual Medicine in volume 9, issue 2. The abstract is publicly available. Information on the measure of quality of life that was used is also publicly available.

Jul 052011

A new study looking at transsexual health just came out. This one looked at the well-being and sexual health of transmen after sex reassignment surgery ( SRS – phalloplasty in this case). Unfortunately, I don’t have access to the full article so I can’t go into too much detail.

The study was conducted in the Netherlands, with 49 transmen. Most of the men had had phalloplasty on average eight years before the study and reported an increase in sexual activity after transition/surgery. They report that they can have orgasms, and that the quality of their orgasms has changed as a result of transition. Despite high rates of surgical complications, most were happy with the results of their sexual reassignment surgeries. They were also generally happy people.

These things may seem like, “Well… duh.” But this is the first study I’ve seen that confirms that “common sense” idea. I’m glad to see it. What do you think?