In this context, comorbidity means: having psychic disorder(s) next to being transgender. On this page we will discuss some frequently occurring comorbidities. In many cases one can wonder whether being a transgender person might be causing (or: aggravating) the comorbidity.

Anxiety disorders
Anxiety disorders often occur in transgender people. This is very understandable: if one has lived for many years with body parts that don’t feel right, if one dares to question their own gender identity and (if applicable) one has the intention to change their appearance (gender expression) and behavior (gender role), many certainties are at risk. This also means that it is no wonder that transgender people have worries about their future, feel insecure about the extent to which their environment will accept them, have doubts whether they will be able to retain their jobs, etc.

In our view transgender people who have an anxiety disorder as comorbidity should not be treated differently than transgender people without such comorbidity. They certainly should not be placed under the guardianship of a gatekeeper: they are, just like any other human being, perfectly capable of making their own judgments and to decide for themselves whether they need help from a supportive psychologist, and what kind of help that should be.

Autism (e.g. Asperger)

Many transgender people are diagnosed with a form of autism, for instance Asperger. It is not so sure this is justified. Let’s look at the DSM-IV-TR-criteria for Asperger, and consider (in violet) what effects our background may have on these criteria:

1. Qualitative impairment in social interaction, as manifested by at least two of the following:

• marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
• failure to develop peer relationships appropriate to developmental level
• lack of spontaneously seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
• lack of social or emotional reciprocity

In their youth, transgender persons may have had a different experience in contacts with peers of the same age than other people have because they felt that they did not fit in: neither with peers who were assigned the same gender at birth, nor with those who were assigned the other gender at birth. Later in life they can also face rejection from their environment due to their being different. This means they have had to live alone more often than the average population (and often still are single), which may lead to compensatory behavior (1st bullet) or may simple have resulted in little experience in getting or sustaining relationships (bullets 2, 3, and 4).

2. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

• encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
• apparently inflexible adherence to specific, non-functional routines or rituals
• stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
• persistent preoccupation with parts of objects

Transgender people may have a strong preoccupation with having different body parts or with being a man/woman (1st bullet) or show compensatory behavior for having difficulties in getting relationships (4th bullet, see explanation for this). This may wrongly lead psychologists to believe this requirement is met.

3. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

Many transgender people also have difficulties in sustaining relationships later in life. If someone has often been rejected for being different, such problems are to be expected. “Functioning in the workplace”: many transgender people are unemployed, sometimes due to their own mistakes but also often due to prejudices about being a transgender person in the workplace.

4. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

In general transgender people will not have any problems in this area...

5. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

In general transgender people will not have any problems in this area...

6. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

In general transgender people will not have any problems in this area...

 
According to the NVA (Nederlandse Vereniging voor Autisme) autism is a congenital condition. Our question is whether the characteristics observed in transgender people have been caused by congenital Asperger or whether they are consequential damages caused by a society that is stuck in a rigid binary way of thinking about men and women.

In our view transgender persons with an autistic disorder must be treated in the same way as transgender people where no comorbidity is diagnosed. We see no need to force them to undergo additional examinations or treatments for autism before a hormone therapy or operation can be started. People with autism are often totally capable of making their own judgments.
Source NVA: http://www.autisme.nl
 
Bipolar disorder
Read this article and judge for yourself.
 
Psychoses, schizophrenia
Although it has never been demonstrated that transgender people have an increased risk of psychoses or schizophrenia, the medical world does fear this is the case. They fear that a possible psychosis or schizophrenia isn’t recognized at the start of the hormone therapy and that, if the psychosis or schizophrenia were under control, the desire for treatment for being a transgender person would no longer exist. It is not so sure this is justified: if transgender people don’t have any psychic complaints that point to psychoses or schizophrenia in their daily lives, we don’t see any reason to investigate this thoroughly and for a long period of time in each and every transgender person who seeks treatment!
 
The only relevant question before a treatment is: does the patient understand what the treatment entails. If they do, hormones and/or operations can be prescribed. If they don’t, no treatment can be given.
 
Suicide
There are gatekeepers at VUmc who defend their own role with the argument that psychologists at VUmc regularly prevent suicides in the first few months after the start of a hormone therapy. We like to make two remarks about this:

1) Transgender people often have had a miserable life before they started their transition and still don’t feel well in their body and in society at the moment the hormone therapy starts. They have had to wait for months until the psychologist who decides on treatments finally completed the examination. The moment just prior to the outcome of the result of this examination is often the most miserable moment in the adult life of a transgender person.

2) At VUmc trans women get prescribed relatively high quantities of anti-testosterone (cyproterone acetate, trade name Androcur). One of the adverse reactions to this medicine is that users often (*) suffer from a depressive mood and/or temporary restlessness. VUmc normally prescribes 50 mg daily at the start of a hormone therapy. We have heard from a general practitioner in Germany that he does not prescribe anti-testosterone for trans women unless there are specific reasons to do so. If he does prescribe it, it is in very limited volumes (5 mg per day). The text of the Dutch patient information leaflet on Androcur 50mg can be found here: http://db.cbg-meb.nl/Bijsluiters/h06540.pdf .