Gender Dysphoria and Social Anxiety: An Exploratory Study in Spain

Trinidad Bergero-Miguel, DClinPsy,1,2 María A. García-Encinas, DClinPsy,1,3 Amelia Villena-Jimena, DClinPsy,1,3

Lucía Pérez-Costillas, MD, PhD,1,4,5 Nicolás Sánchez-Álvarez, MPsy,1,3 Yolanda de Diego-Otero, MSc, PhD,1,4
and Jose Guzman-Parra, DClinPsy1,3,6

ABSTRACT

Introduction: Social anxiety in gender dysphoria is still under investigation.

Aim: To determine the prevalence and associated factors of social anxiety in a sample of individuals with
gender dysphoria.
Methods: A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain.
The sample consisted of 210 individuals (48% trans female and 52% trans male).
Main outcome measures: Mini-International Neuropsychiatric Interview (MINI) for diagnosis of social
anxiety disorder, Structured Clinical Interview, Exposure to Violence Questionnaire (EVQ), Beck Depression
Inventory (BDI-II), and Functional Social Support Questionnaire (Duke-UNC-11).
Results: Of the total sample, 31.4% had social anxiety disorder. Social anxiety disorder was highly correlated
with age (r ¼ "0.181; CI ¼ 0.061e0.264; P ¼ .009) and depression (r ¼ 0.345; CI ¼ 0.213e0.468;
P < .001); it is strongly associated to current cannabis use (relative risk [RR] ¼ 1.251; CI ¼ 1.070e1.463;
P ¼ .001) and lifetime suicidal ideation (RR ¼ 1.902; CI 1.286e2.814; P < .001). Moreover, it is signif-
icantly associated to lifetime nonsuicidal self-injury (RR ¼ 1.188; CI 1.018e1.386; P ¼ .011), nationality
(RR ¼ 7.792; CI 1.059e57.392; P ¼ .013), perceived violence at school during childhood and adolescence
(r ¼ 0.169; CI ¼ 0.036e0.303; P ¼ .014), unemployment (RR ¼ 1.333; CI 1.02e1.742; P ¼ .021), and
hospitalization of parents in childhood (RR ¼ 1.146; CI ¼ 1.003e4.419; P ¼ .046). Using multivariable
analysis, the highly significant variables within the model were depression score (odds ratio [OR] ¼ 1.083;
CI ¼ 1.045e1.123; P < .001) and current cannabis use (OR ¼ 3.873; CI ¼ 1.534e9.779, P ¼ .004), also
age (OR ¼ 0.948; CI ¼ 0.909e0.989; P ¼ .012), hospitalization of parents during childhood (OR ¼ 2.618;
CI ¼ 1.107e6.189; P ¼ .028), and nationality (OR ¼ 9.427; CI ¼ 1.065e83.457; P ¼ .044) were asso-
ciated with social anxiety disorder.
Conclusion: This study highlights the necessity of implementing actions to prevent and treat social anxiety in
this high-risk population.
J Sex Med 2016;-:1e9. Copyright ! 2016, International Society for Sexual Medicine. Published by Elsevier Inc.
All rights reserved.
Key Words: Social Anxiety; Social Phobia; Transsexuals; Transgender; Victimization

INTRODUCTION result of this questioning, classification systems for mental

People with gender dysphoria feel a persistent discomfort disorders such as the Diagnostic and Statistical Manual of
with their own biological sex and assigned role.1 Gender Mental Disorders, 5th Edition (DSM-V) have replaced the name
dysphoria was considered a mental disorder until just a few gender identity disorder with gender dysphoria (GD).1
years ago; however, this idea is being questioned strongly.2 As a Furthermore, the binary concept of gender is widely being

5
Received October 23, 2015. Accepted May 22, 2016. Department of Public, Health and Psychiatry, Faculty of Medicine,
1
Mental Health Clinical Unit, University Regional Hospital of Málaga, University of Malaga, Spain;
6
Biomedical Research Institute of Malaga (IBIMA), Málaga, Spain; Grupo Andaluz de Investigación Psicosocial (GAP) (CTS945), Málaga, Spain
2
Transsexual and Gender Identity Unit, University Regional Hospital of Copyright ª 2016, International Society for Sexual Medicine. Published by
Málaga, Málaga, Spain; Elsevier Inc. All rights reserved.
3
Faculty of Psychology, University of Málaga, Málaga, Spain; http://dx.doi.org/10.1016/j.jsxm.2016.05.009
4
Grupo de Investigación en Salud Mental (INTRAM) (PAIDI CTS456),
Málaga, Spain;

J Sex Med 2016;-:1e9 1

2 Bergero-Miguel et al
questioned and we see a shift from pathologizing to a spectrum
identity approach.3
The transgender minority population frequently receives
manifestations of prejudice, victimization, and social stigma.4
Likewise, there are a number of studies that have indicated
how gender nonconformity increases the risk of victimization to
a greater extent than sexual orientation.5,6 Furthermore, it has
been observed that suffering from abuse and victimization
increase the risk of mental disorders.7,8 Consequently, on the
basis of minority stress theory,9,10 the GD population is at higher
risk of developing mental disorders than the general population.
However, previous reports regarding the prevalence of mental
disorders have revealed contradictory findings. Some studies
report that mental disorders are more common,11e13 but other
studies do not show significant differences.14e16 Studies in the
GD population seeking sex reassignment showed that the most
prevalent disorders are affective and anxiety disorders.11,12,17
Moreover, other studies report that hormonal treatment seems
to improve this psychiatric morbidity18e20 and also reduces
perceived stress and cortisol response.21
Regarding the prevalence of current social anxiety disorder
(SAD) (last 30 days) in studies of primary care patients within
the general population, a prevalence between 2%e4.2%
has been reported.22,23 Epidemiological studies estimate a
current prevalence of SAD (last 12 months) at around 5% (range
1.3%e9.1%).24e27 SAD has been associated with different
variable types in the general population: (1) socio-demographic
variables such as being female, young age, employment status,
low income, nationality, etc.23e25; (2) psychiatric comorbidity,
especially different anxiety disorders, affective disorders, and drug
and alcohol abuse/dependence23,27; (3) victimization and/or
abuse, violence experienced at home, sexual abuse, and sibling
victimization28e30; and (4) stressful and traumatic events, such as
separation and hospitalization of parents, birth risk factors, his-
tory of parental mental disorders, unfavorable parental rearing
styles, rejection and lack of emotional warmth, lack of perceived
social support, etc.30e32
In other minority populations, such as identified gay males,
prevalence of SAD in the last 12 months is high, ranging
between 7.3%e8%.33,34 Similarly, in the LGB population,
victimization has been associated with depression and SAD.35
And gender nonconformity independent of sexual orientation
has been associated with increased social anxiety.36,37
Although a reduced number of studies have been performed in
the clinical population with GD, there is another study indi-
cating that SAD was the most prevalent anxiety disorder,
reaching 9.1% (trans male 11.3% and 8.2% trans female) in this
GD Spanish population.17 A feasible hypothesis is that dissatis-
faction with the biological sex at birth and the presence of an
increase in discrimination and victimization events could further
hinder social relationships with respect to other minority pop-
ulations.38,39 On the other hand, to our knowledge, victimiza-
tion experiences in different environments and traumatic and
stressful experiences that may have influenced SAD in persons
with GD have not been studied.
AIMS
The objectives of this study were, primarily, to determine the
prevalence of SAD in a group of patients with GD attending the
Transsexual and Gender Identity Unit (TGIU) of the Regional
University Hospital in Malaga. This study also considered
whether violence suffered during childhood and adolescence,
stressful and traumatic events, perceived social support, and other
sociodemographic and clinical variables were associated with
SAD in this population. The hypothesis raised was that SAD
could be more prevalent in the studied population than in the
general population and environmental factors such as victimi-
zation and stressful events are associated with the development
of SAD.
METHOD
Participants and Settings
In total, 242 patients were eligible for the study, all of whom
attended a clinical psychology consultation at the TGIU between
2011 and 2013. Of these, 18 individuals (7.4%) did not meet
the inclusion criteria, 13 individuals (5.4%) did not compete all
assessment measures and 1 patient (0.4%) refused to participate
in the study, leaving 210 subjects participating in this study. Of
these, 52% were trans female and 48% trans male. The average
age was 27.86 (SD ¼ 9.53) with a range between 14 and 59
years. The TGIU is the only public entity in Andalusia that
provides free health assistance for multidisciplinary treatment of
GD. The Andalusian health care service allows for hormonal
treatment, psychological attention, and surgery for those who
would benefit from the intervention, and was the first region in
Spain to include this service in the public health system. The
standard of care guidelines of the World Professional Association
for Transgender Health were followed at the unit. At the time of
the study, the sixth version of the protocol was followed and the
TGIU was in the process of adopting the seventh version.
Procedure
Each participant was interviewed individually, in various
sessions of approximately 1 hour. Consecutive participants
attending the TGIU were invited to participate in this study
during the recruitment period. The selection criteria: (1) having a
diagnosis of transsexualism in accordance with International
Classification of Diseases, 10 edition (ICD-10)40 evaluated by a
clinical psychologist was an inclusion criterion; (2) having an
active psychotic disorder or severe personality disorder were the
exclusion criteria, and these patients were also excluded from the
TGIU treatment. All participants signed informed consent to
participate in the study and parents signed for participants under
18. The investigation was approved by the Ethics Committee of
J Sex Med 2016;-:1e9
Gender Dysphoria and Social Anxiety
the Regional University Hospital and the principles of the Hel-
sinki declaration were followed.
Statistical Analysis
Categorical variables were compared with the c2 test, and
Pearson’s correlation was used for continuous variables. There-
after, several multivariable logistic regression models were used
with the presence of SAD (Yes/No) as the dependent variable.
The variables that were statistically significant in the univariate
analysis or that were considered clinically relevant because they
were related to SAD24,25,30,32 were considered independent
variables. To account for the relatively small number of cases in
the study, we built 3 partial models considering different groups
of independent variables, and at the end we performed a final
model to describe the final associated factors in our study.
Sociodemographic and treatment variables (gender, age,
employment status, nationality, and current hormonal treat-
ment) were included in Model 1. Model 2 included mental
health and substance use/abuse-related variables (depression
score, suicidal ideation lifetime, self-injury lifetime, alcohol
consumption, cannabis consumption). Model 3 was built
considering victimization and stress-related variables (perceived
violence suffered at school during childhood and adolescence,
perceived social support, and hospitalization of parents during
infancy). The final model (Table 3) included the significant
variables of the 3 partial models (depression score, age, nation-
ality, cannabis consumption, and hospitalization of parents
during infancy). However, given the relatively small sample and
the use of previous univariate screening, it must be considered as
an exploratory study whose findings can hardly be generalized to
different populations. As a measure of good adjustment to the
regression model, the Cox & Snell pseudo-R2 test was used as a
parameter. The statistical analyses were performed using SPSS for
Windows, Version 15.0 (SPSS Inc, Chicago, IL, USA).
Main Outcome Measures
Structured Clinical Interview
This specific instrument was designed at the TGIU and was
administered to collect demographic and clinical data. It was
used to collect the following variables: (1) sociodemographic
details, such as age, gender, nationality, civil status, education,
employment status, and employment lifetime; (2) relevant clin-
ical information, such as alcohol consumption (the consumption
of alcohol was considered moderate/high if the patient consumed
at least more than once a week and 3 or more drinks on average
on each occasion), current cannabis use (the patient reported
cannabis use in the past year), lifetime suicidal ideation and
attempts, and lifetime nonsuicidal self-injury; and (3) stress-
related variables such as vital lifetime events suffered (the death
of a relative/spouse/mother/father/brother/friend, start of a rela-
tionship, serious illness of the parents/spouse, taking care of
someone with a chronic illness, parents’ divorce, lack of
employment, loss of home, eviction, being arrested,
J Sex Med 2016;-:1e9
3
incarceration, military service, and illness), level of rejection of
the biological sex (to what extent did you feel rejection towards
your biological gender? Likert scale of 0 to 5), external pressure
to adopt the biological sex role (to what extent did you feel
external pressure to conform your behavior to your biological
sex? Likert scale of 0 to 5), having ever been subjected to
aggression, sexual abuse during childhood and adolescence,
parent hospitalization and separation during childhood, parents’
psychiatric antecedents, and job seeking discrimination (have you
ever felt discriminated against when you were applying for a job?
yes/no).
The Mini-International Neuropsychiatric Interview (MINI)
The MINI41 is a semistructured interview used to differentiate
those who comply with the criteria for SAD. This instrument has
appropriate psychometric properties in the Spanish population.42
Exposure to Violence Questionnaire (EVQ)
The EVQ43 was used to evaluate, in a retrospective manner,
the frequency with which the person was a victim and/or a
witness to violence (verbal, physical, threatened) in various
environments (home, school, neighborhood) during childhood
and adolescence. It features 2 scales (victimization and exposure
to violence), but only the victimization scale was used. It has
adequate psychometric properties.
Beck Depression Inventory II (BDI-II)
The BDI-II44 is a 21-item self-report that evaluates symptoms
of depression and the stage thereof (mild, moderate, and serious).
This instrument is widely used in clinics and for investigation,
and has adequate psychometric properties for the Spanish
population.45
Duke-UNC-11 Functional Social Support Questionnaire
(DUKE-UNC)
The DUKE-UNC46 evaluates perceived social support via 11
items to which the subject must respond on a Likert scale of 0 to
5 points. The instrument was validated and has adequate psy-
chometric properties for the Spanish population.47
RESULTS
Descriptive Analysis
The results indicate that 66 (31.4%) of 210 patients evaluated,
30 trans female (27.5%) and 36 trans male (35.6%) presented
SAD. Of the total sample, 12.8% had mild depression (range
14e19), 12.4% moderate depression (range 20e28), and 7.14%
serious depression (>28). In addition, 23.8% had attempted
suicide, 50.9% had suicidal ideation, and 16.2% nonsuicidal
self-injury during their lifetime. Fully 80.0% of participants had
been subjected to aggression at least once in their lifetime. The
average score of victimization in the EVQ was 12.58 (SD ¼
7.88). Regarding different environments, victimization at school
had the highest average score, with 5.09 (SD ¼ 3.38), followed
4 Bergero-Miguel et al
by victimization in the neighborhood with 4.46 (SD ¼ 3.21),
and finally victimization in the family environment with 3.01
(SD ¼ 3.45). Victimization at school had the highest score in
trans females (5.69 vs 4.44; Z ¼ "2.675; P ¼ .007).
Clinical and Sociodemographic Variables
The results related to sociodemographic and clinical variables
appear in Table 1. SAD was very significantly correlated with age
(r ¼ "0.181; CI ¼ 0.061e0.264; P ¼ .009); in addition, it was
very significantly associated with current cannabis consumption
(relative risk [RR] ¼ 1.251; CI ¼ 1.070e1.463; P ¼ .001), to
depression (r ¼ 0.345; CI ¼ 0.213e0.468; P < .001) and to
lifetime suicidal ideation (RR ¼ 1.902; CI ¼ 1.286e2.814; P <
.001), and moreover, it was significantly associated with unem-
ployment status (RR ¼ 1.333; CI ¼ 1.020e1.742; P ¼ .021),
and to lifetime nonsuicidal self-injury (RR ¼ 1.188; CI ¼
1.018e1.386; P ¼ .011).
Victimization and Stress-related Variables
Results related to victimization during childhood and adoles-
cence, as well as vital stress events appear in Table 2. SAD was
significantly correlated with the level of perceived violence in
school during childhood and adolescence (r ¼ 0.169; CI ¼
0.036e0.303; P ¼ .014), and also was significantly associated
with the hospitalization of parents during childhood (RR ¼
1.146; CI ¼ 1.003e4.419; P ¼ .046). Marginally significant
correlation was found in perceived social support (r ¼ "0.134;
CI ¼ "0.276 to 0.002, P ¼ .053).
Multivariable Analysis
In the final logistic regression model (Table 3), the following
predictors were maintained as significant variables: depression
score (odds ratio [OR] ¼ 1.083; CI ¼ 1.045e1.123 P < .001),
current cannabis use (OR ¼ 3.873; CI ¼ 1.534e9.779, P ¼
.004), age (OR ¼ 0.948; CI ¼ 0.909e0.989; P ¼ .012;),
hospitalization of parents during childhood (OR ¼ 2.618; CI ¼
1.107e6.189; P ¼ .028), and nationality (OR ¼ 9.427; CI ¼
1.065e83.457; P ¼ .044), with a Cox & Snell pseudo-R2 of
0.222.
DISCUSSION
The objective of the study was to analyze prevalence and
associated factors of SAD in a Spanish sample of transgender
individuals. To our knowledge, this is the first study focusing on
risk factors involved in social anxiety disorder in the population
with gender dysphoria. A high prevalence of SAD was found in
the studied sample. The factors independently associated with
SAD were age, nationality, depression, cannabis consumption,
and hospitalization of parents during childhood.
The study found that the prevalence of SAD was 31.42%,
making it higher than in the general population.22,23 This per-
centage also is higher than in a study carried out in a different
Spanish region.17 This finding is consistent with several studies
indicating that the trans population exhibits high levels of anxiety
symptoms,48 particularly prior to sexual reassignment treatment,
and according to these results social anxiety was very frequent in
the population with gender dysphoria in this study. With respect
to variables associated with SAD, some sociodemographic vari-
ables (age and nationality) and psychopathological comorbidities
(depression) were found to be independently associated, and
those results are similar to those found in the general popula-
tion.27,49,50 A significant relationship between SAD and symp-
toms of depression was found in this study, which is consistent
with previous literature.51 Generally, the age of SAD onset
precedes that of depression, and there is an association between
the presence of depressive symptoms, greater severity, and
functional impairment.51,52
Regarding victimization during childhood and adolescence,
comparing the results to a sample of students,43 the average of
perceived violence at school in the GD population was higher
(M ¼ 5.09 vs M ¼ 3.10); whereas scores on violence in the
family were similar (M ¼ 3.01 vs M ¼ 2.20). This is consistent
with data from other studies in which transgender populations
were more likely to be harassed, victimized, or suffer abuse at
school, with negative repercussions in adult life.53,54
Although in the univariate analysis, the perceived victimiza-
tion at school during childhood and adolescence was associated
with SAD, in the final predictive model this variable was not
significantly associated. However, given the limitations of the
study, this may be due to the relatively small sample, a situation
that future studies should address. Instead, some vital stressful
factors such as hospitalization of parents during childhood were
associated with SAD as has been observed in other studies about
of the general population.30
Regarding cannabis use, a recent study in the trans population
showed that social avoidance and fear of negative evaluation were
associated with current cannabis use, and victimization was asso-
ciated with lifetime (but not current) cannabis and cocaine use.
This may suggest that violence may be a risk factor for social
distress and avoidance, and cannabis may be used as self-medica-
tion,55 but this aspect remains to be clarified. On the other hand, in
the general population there is some evidence that cannabis can be
a risk factor for the development of SAD, but results in prospective
studies have been inconsistent.56,57 Given the high prevalence of
social anxiety in the GD population, the consumption of cannabis
could be especially damaging, although future longitudinal studies
within this population should clarify this assumption.
Furthermore, hormonal treatment was associated with SAD in
the univariate analysis; however, the association remains insig-
nificant in the multivariable analysis, which is not in agreement
with previous studies that indicated that hormonal treatment
improved anxiety symptoms.18,19 However, the validity of the
statistical results may be affected by the cross-sectional design of
the study, as several studies with longitudinal designs have shown
that hormone therapy reduces symptoms of social anxiety and
J Sex Med 2016;-:1e9
Gender Dysphoria and Social Anxiety 5

Table 1. Sociodemographic and clinical variables associated with social anxiety disorder
Social anxiety No social anxiety
n ¼ 66 n ¼ 144
Mean (SD) Mean (SD) Correlation CI P
Age 25.32 (7.33) 29.02 (10.19) "0.181 0.061e0.264 .009
BDI 16.21 (11.19) 8.87 (8.30) 0.345 0.213e0.468 <.001
n (%) n (%) RR CI c P
Gender 1.207 0.891e1.634 1.604 .205
Trans female (reference) 30 (27.5) 79 (72.5)
Trans male 36 (35.5) 65 (64.4)
Nationality 7.792 1.059e57.392 6.115 .013
Foreigners (reference) 1 (5.6) 17 (94.4)
Spaniards 65 (33.9) 127 (66.1)
Educational level 0.903 0.546e1.493 0.220 .896
Primary (reference) 17 (33.3) 34 (66.7)
Secondary/university 48 (30.4) 110 (69.6)
Civil status 1.681 0.854e3.307 2.436 .119
Married/living as a couple (reference) 9 (21.4) 33 (78.6)
Single 57 (33.9) 111 (66.1)
Occupational status 1.333 1.020e1.742 5.306 .021
Employment/other (reference) 33 (25.6) 96 (74.4)
Unemployed 33 (40.7) 48 (59.3)
Employment lifetime 1.528 0.435e5.369 1.196 .274
Employment at least once (reference) 50 (29.6) 119 (70.4)
Never worked 14 (38.9) 22 (62.1)
Current hormonal treatment 1.549 0.999e2.402 4.314 .038
Yes (reference) 18 (23.1) 60 (76.9)
No 48 (36.9) 82 (63.1)
Alcohol consumption 1.093 0.949e1.259 1.781 .181
Low or none (reference) 52 (29.5) 124 (70.5)
Moderate or high 14 (41.2) 20 (58.8)
Current cannabis consumption 1.251 1.070e1.463 11.973 .001
No (reference) 48 (26.8) 131 (73.29)
Yes 18 (58.1) 13 (41.9)
Attempt of suicide lifetime 1.136 0.949e1.360 2.237 .135
No (reference) 46 (28.8) 114 (71.3)
Yes 20 (40.0) 30 (60.0)
Suicidal ideation lifetime 1.902 1.286e2.814 13.532 .000
No (reference) 20 (19.4) 83 (80.6)
Yes 46 (41.3) 61 (57.0)
Nonsuicidal self-injury 1.188 1.018e1.386 6.492 .011
No (reference) 49 (27.8) 127 (72.2)
Yes 17 (50.0) 17 (50.0)
BDI ¼ Beck Depression Inventory; RR ¼ relative risk.

therefore these results should be interpreted with caution, given
the limitations of the final model presented in this study.
This research has some limitations. The sample was not
representative of the whole transgender population, as an
unknown proportion of these individuals did not actively seek
sex reassignment surgery and therefore these individuals did
not visit the TGIU. It is probable that other variables are
associated with SAD that have not been taken into consider-
ation and would be invaluable in a social anxiety study; for
example, according to the minority stress model, variables
related to expectations of discrimination and internalized
transphobia. There is no control group from the general pop-
ulation, which also has its limitations. However, since this is a
cross-sectional study, a cause and effect in the relationships
between variables cannot be established, nor with the factors
involved in the etiology of SAD in this specific population.
With respect to the multivariable model, due to the univariate
screening used in the preliminary analysis and the large number
of variables with respect to the small sample size of the study,
this analysis should be considered as exploratory and there is a

J Sex Med 2016;-:1e9

6 Bergero-Miguel et al

Table 2. Victimization, perceived social support and stress events factors associated with social anxiety disorder
Social anxiety No social anxiety
n ¼ 66 n ¼ 144
Mean (SD) Mean (SD) Correlation CI P
Social support (Duke-UNC) 41.62 (9.70) 44.43 (9.72) "0.134 "0.276 to 0.002 .053
Direct violence total score (EVQ) 14.12 (7.59) 11.86 (7.94) 0.134 "0.002 to 0.280 .054
Violence at school 5.93 (3.37) 4.70 (3.33) 0.169 0.036 to 0.303 .014
Violence on the street 4.98 (3.28) 4.21 (3.15) 0.112 "0.029 to 0.224 .107
Violence at home 3.19 (3.46) 2.92 (3.45) 0.036 "0.107 to 0.168 .603
Number of stressful events 3.68 (2.14) 3.91 (2.35) "0.148 "0.183 to 0.074 .492
Rejection level of biological sex (0e5) 4.71 (0.76) 4.48 (1.15) 0.102 "0.016 to 0.195 .141
External pressure to adopt the 3.42 (1.83) 3.08 (2.06) 0.080 "0.040 to 0.203 .252
biological sex (0e5)
n (%) n (%) RR CI c P
Been object of aggression 1.301 0.698 to 2.425 0.668 .414
No (reference) 11 (26.2) 31 (73.8)
Yes 55 (32.7) 113 (67.3)
Discrimination to find a job (n ¼ 194) 0.993 0.804 to 1.227 0.000 .997
No (reference) 39 (31.5) 85 (68.5)
Yes 22 (31.4) 48 (68.6)
Sexual abuse during childhood (n ¼ 202) 1.001 0.892 to 1.122 0.000 .938
No (reference) 54 (30.7) 122 (69.3)
Yes 8 (30.8) 18 (69.2)
Sexual abuse during adolescence 0.996 0.903 to 1.099 0.005 .885
No (reference) 56 (30.8) 126 (69.2)
Yes 6 (30.0) 14 (70.0)
Parent hospitalization during childhood 1.146 1.003 to 4.419 3.977 .046
No (reference) 50 (28.6) 125 (71.4)
Yes 16 (45.7) 19 (54.3)
Separation of parents during childhood 1.056 0.559 to 1.995 0.028 .867
No (reference) 46 (31.1) 122 (68.9)
Yes 20 (32.3) 42 (67.7)
Psychiatric antecedents (mother) 0.981 0.830 to 1.159 0.051 .822
No (reference) 50 (31.8) 107 (68.2)
Yes 16 (30.2) 37 (69.8)
Psychiatric antecedents (father) 0.935 0.792 to 1.103 0.597 .440
No (reference) 51 (32.9) 104 (67.1)
Yes 15 (27.3) 40 (72.7)
Duke UNC ¼ The Duke-UNC functional social support questionnaire; EVQ ¼ Exposure to Violence Questionnaire; RR ¼ relative risk.

risk of overfitting. Finally, SAD could be overrepresented in
persons with GD because similar symptoms were experienced,
such as avoiding social contacts, fear of being mocked, etc.
CONCLUSIONS
To conclude, we can state that the results of the study support
our first hypothesis concerning the presence of a large proportion
of transgenders who have SAD. However, the second hypothesis
has partially been supported, since only 1 variable related to
stressful events was associated with social anxiety; additionally, the
perceived violence in childhood and adolescence was significantly
associated only in the univariate analysis. Although a causal
relationship may not be derived from cross-sectional studies, we
can hypothesize that SAD is related to GD, at least in the early
stages of treatment. We also found an alarmingly high level of
perceived victimization at school. These results suggest that both
clinicians and policymakers should be aware of these factors and
should try to achieve the implementation of preventive in-
terventions to improve social integration of transgender minor-
ities. Furthermore, the high level of perceived violence at school
during childhood and adolescence leads us to recommend in-
terventions to ensure a safe school environment for this popula-
tion. However, future longitudinal studies with larger samples and
using control groups are needed to better understand the rela-
tionship between social anxiety and gender dysphoria.

J Sex Med 2016;-:1e9

Gender Dysphoria and Social Anxiety 7

Table 3. Multivariate logistic regression with social anxiety (c) Analysis and Interpretation of Data
disorder as dependent variable (MINI) José Guzmán-Parra; Yolanda de Diego-Otero; Nicolás Sánchez-
Álvarez; Lucía Pérez-Costillas
MINI OR adjusted CI P value
Age 0.948 0.909 to 0.989 .012 Category 2
Nationality 9.427 1.065 to 83.457 .044 (a) Drafting the Article
Current cannabis 3.873 1.534 to 9.779 .004 José Guzmán-Parra; Trinidad Bergero-Miguel; Maria A. Garcia-
consumption Encinas; Amelia Villena-Jimena
Depression (BDI) 1.083 1.045 to 1.123 <.001 (b) Revising It for Intellectual Content
Parent hospitalization 2.618 1.107 to 6.189 .028 Yolanda de Diego-Otero; Lucía Pérez-Costillas; Nicolás
during childhood Sánchez-Álvarez

BDI ¼ Beck Depression Inventory; MINI ¼ The Mini-International Neuro- Category 3

psychiatric Interview; OR ¼ odd ratios.
ACKNOWLEDGMENT
We wish to thank all members of the Transsexuality and
Gender Identity Unit of the University Regional Hospital of
Malaga, and all those with gender dysphoria who participated in
this research. The author wishes to thank David W.E. Ramsden
for valuable assistance correcting the English version of
the manuscript and also the technical assistance of
L. Sanchez-Salido.
Corresponding Author: Yolanda de Diego-Otero, MSc, PhD,
Mental Health Research Unit, Plaza Hospital Civil s/n, Hospital
Civil 1a Planta Pabellón 4, CP: 29009, Málaga, Spain.
Tel: þ0034-951290309; E-mail: yolanda.dediego@ibima.eu
Conflict of Interest: The authors reports no conflicts of interest.
Funding: This project was partially financed by the Health
Investigation Fund Carlos III Health Institute. Spanish Ministry
of Health, file number 01/0447 entitled: Transsexuality in
Andalucía: endocrine psychiatric morbidity and surgical and eval-
uation of therapeutic intervention. Experience by the first Unit of
reference in Spain (2001e2013). This study was partially sup-
ported by grant No. PI06-1339, funded by the Carlos III Health
Institute. Spanish Ministry of Health, Social Affairs and
Equality, Spain; and by grant No. PI07-0157 funded by Anda-
lusian Regional Ministry of Health and CTS546 funded by the
Andalusian Regional Ministry of Innovation, Andalusia, Spain.
Partial funds of EU-FEDER (Fondo Europeo de Desarrollo
Regional). YDDO is recipient of a “Nicolas Monarde” contract
from the “Servicio Andaluz de Salud. Consejería de Salud. Junta
de Andalucía”.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Trinidad Bergero-Miguel; José Guzmán-Parra
(b) Acquisition of Data
Trinidad Bergero-Miguel; Maria A. Garcia-Encinas; Amelia
Villena-Jimena
(a) Final Approval of the Completed Article
Trinidad Bergero-Miguel; María A. García-Encinas; Amelia
Villena-Jimena; Lucía Pérez-Costillas; Nicolás Sánchez-Álvarez;
Yolanda de Diego-Otero; José Guzmán-Parra
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