The frequency of personality disorders in patients with gender identity disorder

The frequency of personality disorders in patients with gender identity disorder



Azadeh Mazaheri Meybodi1, Ahmad Hajebi2, Atefeh Ghanbari Jolfaei3

Received: 8 July 2013           Accepted: 15 March 2014          Published: 10 September 2014


Background: Co-morbid psychiatric disorders affect prognosis, psychosocial adjustment and post-surgery satisfaction in patients with gender identity disorder. In this paper, we assessed the frequency of personality dis- orders in Iranian GID patients.

Methods: Seventy- three patients requesting sex reassignment surgery (SRS) were recruited for this cross- sectional study. Of the participants, 57.5% were biologically male and 42.5% were biologically female. They were assessed through the Millon Clinical Multiaxial Inventory II (MCMI- II).

Results: The frequency of personality disorders was 81.4%. The most frequent personality disorder was nar- cissistic personality disorder (57.1%) and the least was borderline personality disorder. The average number of diagnoses was 3.00 per patient.

Conclusion: The findings of this study revealed that the prevalence of personality disorders was higher among the participants, and the most frequent personality disorder was narcissistic personality disorder (57.1%), and borderline personality disorder was less common among the studied patients.

Keywords: Personality disorder, Gender identity disorder.
Cite this article as: Mazaheri Meybodi A, Hajebi A, Ghanbari Jolfaei A. The frequency of personality disorders in patients with gender identity disorder. Med J Islam Repub Iran 2014 (10 September). Vol. 28:90.


Strong and stable preference to live in form of the other gender is the clinical symptom of Gender Identity Disorders (GIDs) (1,2). Based on the revised text of the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV- TR), this disorder causes continuous dissat- isfaction of the gender or feeling of inap- propriateness of the current sexual role.  GID affects social, occupational and other essential functions (3). The extent of preva- lence of GID is not similar in different countries (4,5), and perhaps it is more widespread than what is presumed (6,7). The prevalence of GID is estimated 1:10,000 to  1:20,000 in  men and  1:30,000

to  1:50,000  in  women  (8)  and  the sexual ratio (biological males to biological fe- males) is between 3 and 5 to 1 (1). Howev- er, this ratio seems to be close to 1 to 1 in our country (9).

In a cross-sectional study, the prevalence of MTF and FTM GID was calculated as 1:145,000 and 1:136,000, respectively, and the total prevalence as 1:141,000. The sex ratio of MTF to FTM GID was 0.96:1(12).

There are some researches on psychiatric co-morbidities with GID. However, the findings are scattered due to the differences in the number of patients, methods of sam- ple recruitment and instruments. Studying psychiatric comorbidities in GID patients is important in several aspects:

Understanding these disorders contributes to   clarification   of   GID   nosology. Some scholars classified GID as a part of border- line personality disorder (BPD) (10 to 13). For example, Murray has suggested that GID in men is a presentation of character structure matched with Kernberg’s criteria for        borderline   personality   organization. Transsexualism is even considered as a subset of borderline personality disorder (10). Seikowski et al. opposed to the corre- lation between GID and borderline person- ality disorder, regarding GID as a separate disorder, which may sometimes show bor- derline personality disorder symptoms (14). Another important aspect of studying co- morbid psychiatric disorders in GID is helping the clinicians to make definite and accurate diagnosis. GID patients usually look for hormone-based treatment or sex reassignment surgery (SRS), but in many cases the patients asking for SRS have psy- chiatric disorders other than GID such as personality disorders which should be  con-sidered before surgery (1,9).

Furthermore, co-morbid psychiatric dis- orders affect prognosis, psychosocial ad- justment and post-surgery satisfaction in GID patients (15,16).

Although social factors and cultural background affect GID, findings in one country could not be generalized to other countries without cautious considerations.

Researches on GID subjects in countries other than Western countries could be help- ful in identifying the similarities and differ- ences of features and comorbidities of GID between different nationalities with differ- ent cultural, political and religious orienta- tions as these factors may affect attitudes towards sex (1-5). Researches of this kind are small in number; therefore, this study was designed to assess the frequency of personality disorders in Iranian GID pa- tients




Eighty- three patients with a primary Axis I diagnosis of GID according to the criteria outlined in the Diagnostic and Statistical Manual  of  Mental  Disorders,  4th  edition

(DSM-IV), participated in this study. The patients were admitted to the outpatient sex clinic in Tehran Institute of Psychiatry, Tehran, Iran between October 2006 and March 2007.

The patients were evaluated by two senior psychiatrists of Iran University of Medical Sciences faculty who had special interest in this area. The participants were recruited after an unstructured psychiatric interview in order to approve the diagnosis of GID and exclude the current mood disorders and psychotic disorders to decrease the effect of axis I disorders on the diagnosis of person- ality disorders. Seven patients were exclud- ed as they met the criteria of current mood disorders.

This study was approved by the Review Board of the Psychiatry Department of Iran University of Medical Sciences. All the participants signed a written informed con- sent after they were provided with a com- plete description of the study. It is notewor- thy to mention that the test results of three patients were excluded due to low validity scales scores of the MCMI II.



In this study, the Millon Clinical Multiax- ial Inventory II (MCMI- II) was used to assess comorbid personality disorders.

The MCMI II is an inventory with I75 items designed to measure personality dis- orders (17). It provides measures of eight basic personality patterns, three more se- vere pathological personality styles  and nine clinical personality disorders. In this inventory, a score higher than 74 indicates the presence of personality disorder.

The reliability and validity of the MCMI II is generally sound. Based on the Millon studies, the internal consistency of the test is high. The average of 22 clinical scales is 0.89, and the range is from 0.81 to 0.95  (18; 19). The validity and reliability of the Persian version of the MCMI II have been approved in Iran (20).



Seventy  (95.89%)  patients  were   candidates for sex reassignment, and they were referred to pass the legal process of surgical sex reassignment. Forty –two (57.5%) pa- tients were the MTF-type and 31 (42.5%) were the FTM-type. The Mean±SD age of the patients was 25.3±6.4 years. Due to Iran’s regulations, same gender marriage is not allowed and transsexuals cannot get married before sex reassignment, so all the examined patients were single (95.7%) or divorced (4.3%).

The most frequent personality disorder was narcissistic personality disorder (57.1%) and the least frequent was border- line personality disorder; only one sample exhibited borderline personality disorder (1.4%) (Table1).

Table 1. The Frequency of Personality Disorders in Patients


N               %               N % N %               X2                              P
Narcissistic 40 57.1 25 64.1 15 48.4 1.742 0.187
Obsessive-compulsive 27 38.6 13 33.3 14 45.2 1.020 0.313
Masochistic-sadistic 24 34.3 11 28.2 13 41.9 1.445 0.229
Paranoid 18 25.7 11 28.2 7 22.6 0.286 0.593
Antisocial 16 .9 8 20.5 8 25.8 0.274 0.600
Histrionic 12 17.1 4 10.3 8 25.8 2.940 0.086
Schizoid 11 15.7 11 28.2 10.374 0.001
Schizotypal 11 15.7 11 28.2 10.374 0.001
Avoidant 11 15.7 11 28.2 10.374 0.001
Passive-aggressive 9 12.9 8 20.5 1 2.3 4.607 0.032
Self-defeating 6 8.6 5 12.8 1 2.3 2.029 0.154
Dependent 6 8.6 6 15.4 5. 216 0.22
Borderline 1 14 1 2.6 0.806 1.000
Personality disorder (total) 57 81.4 35 89.7 22 71 4.026 0.045


The  average  number  of  diagnoses   was Schizoid, schizotypal, and avoidant personality disorders with p<0.001 and passive-aggressive and dependent personality disorders with p<0.05 were more prevalent in biological males than biological females (p>0.01).

Hormone  replacement  therapy  had beenadministered for the majority of the patients (92.9%) before referral to Teheran Institute of Psychiatry. Of the participants, 5.7% had a history of self-harm (including cutting  and burning).There was not a significant difference in the frequency of personality disorders based on marital status, receiving hormone therapy and history of self-harm.

  • per client (Table 2).


Number of Co- Occurring Personality Disorders Frequency %
1 10 0.314
2 12 17.1
3 10 3.14
4 8 4.11
5 9 9.12
6 5 1.7
7 3 3.4




Personality disorders were common in this study (57 cases, 81.4%). The rate of personality disorders were 41.9% in Hep et al. study (21), and it was 19.8% in Harold- son and Dahal study (22). It was found that males had more axis II disorders, and this finding is consistent with that of previous studies (8,15). In our research, the most common type of personality disorder was narcissistic personality disorder, which was observed in more than half of the patients (57.1%). In the study of Hep et al. as well  as that of Haroldson and Dahal, cluster B personality disorders were more common than the other two clusters. Applying Struc- tured Clinical Interview for DSM-IV axis II disorders (SCID-II), Hep et al. examined GID patients in Switzerland (20). The re- sults revealed a comorbidity of personality disorders in 41.9 % of the patients (13 pa- tients); and the most frequent personality disorders were cluster B (7 patients) fol- lowed by cluster C (6 patients): Cluster A: 16.1%, Cluster B: 22.6%, Cluster C:  19.4%,  NOS  PD:  6.5%  (run  among GID samples).The frequency of axis II disorders did not correlate with the patients’ gender, age and state of treatment.

In 2004 in Sweden, Haraldsen and Dahl, applying SCID-II, found the following re- sults in 41.8 % of the patients (17 patients) (22):

Cluster A: 5 patients (5.8%)

Cluster B: 7 patients (8.1%)

Cluster C: 5 patients (5.8%)

NOS: 0 (run among mixed pre and post SRS samples).

Using clinical interview, based on DSM- III, Levin and Bodlund reported personality disorders in 66% of the surgery candidates and in 37% of GID samples (24,25).

Using SCID–II Bodlund et al. found the prevalence of comorbidity of personality disorders as follows:

Cluster B: 22.2%, Cluster C:11.1%, Cluster A: N= 0 (25)

Mededdu reported the presence of per- sonality disorders in 52% of the surgery candidates and stated that narcissistic per- sonality disorder was the commonest disor- der.

It can be concluded that personality dis- orders are more widespread among surgery candidates than the general GID samples. Furthermore, the higher rates of narcissistic personality disorder in these patients (sur- gery candidates) may be due to the fact that they are more preoccupied with their own appearance and beauty and need more praise by others.

Moreover, it is not clear why personality disorders are common among these pa- tients; it might be that each of these two disorders makes the patient vulnerable to the other. Hoopes and Meyer found that GID patients try hard to adjust to their bio- logical gender and sexual role, but the ad- justment costs their personality. Besides,  the hard circumstances, in which most GID patients live may predispose them to other psychiatric disorders.

On the other hand, shared symptoms and same age of emergence may result in great- er number of diagnosis  of personality   dis-

orders particularly cluster B in GID pa- tients, or perhaps the patients are inclined  to be affected by both disorders due to sim- ultaneous common etiologies like a possi- ble genetic connection.

Therefore, various personality disorders should be examined in each individual with GID (22). In GID patients, the comorbidity of personality disorder was accompanied with poor prognosis (15,16).

In some studies, borderline personality disorder is acknowledged to be the most common personality disorder co-morbidity in GID patients (1,2). Murray has suggested that transsexualism is a presentation of bor- derline personality organization and even a subgroup of borderline personality disor- der. Murray compared transsexual males, BPD males and homosexual males with controls. Compared to controls, transsexual and BPD patients had more aggression, poorer reality testing and lower levels of object relations, but Rorschach test results were similar in both groups (10). Seikowski and colleges, however, found no sign of borderline personality disorder or other personality disorders in 80% of 164 trans- sexual patients, applying Beck Depression Scale (BDI), Freiburg Personality Invento- ry (FPI) and Questionnaire for Assessment of One’s Own Body (FBek). In addition, they believed that the diagnosis of BPD in other cases could be contributed by depres- sion, low composure, poor socialization  and low self-confidence. Therefore, they  did not approve the correlation between GID and borderline personality disorder  and considered the GID as a distinct disor- der whose symptoms might sometimes overlap with borderline personality traits (14). In this study, the elevation of the bor- derline personality scores was  found  only in one case (1.4%). This implies the scarci- ty of this disorder in GID patients. Howev- er, the diagnosis of borderline personality pattern is also based on many combinations of personality scores including 2, 4, 5 and 8 (avoidant, histrionic, narcissistic, antisocial, and self-defeating). Therefore, despite the fact   that   borderline   personality disorder was only identified in one case, borderline personality pattern was observed in most of the cases, which is consistent with the re- sult of some studies (26-28).

The difference between the results of the mentioned studies may originate from dif- ferent settings, instruments, number of pa- tients and methods of sampling.

The validity and reliability of the MCMI- II in GID patients were not evaluated; therefore, the findings should be interpreted with caution. There was not a significant difference in the frequency of personality disorders based on marital status, hormone therapy or history of self-harm, and this may be due to the small number of di- vorced patients, patients who did not re- ceive hormone therapy and patients with history of self-harm. In our study, there was no normal control and this is  considered one of the limitations of this study.

This study also faced other limitations. Patients in our research may be imperfect samples of all GID patients. In Iran, GID patients are guided to Tehran Institute of Psychiatry when they request a new official identity or sex reassignment surgery (SRS). Consequently, samples in this study can be considered a sample of patients who have more psychiatric problems or more intense conflicts with their conceived identity. Fur- thermore, although according to some stud- ies there is a fair clinical concordance be- tween the MCMI II and DSM-III-R criteria, some other studies showed that the MCMI II is not congruent with Structured Clinical Interview for DSM-III-R (29-31). There- fore, it is a limitation of our study that only the MCMI II test, which is a self-report questionnaire, was applied and personality disorder was not assessed by other standard tests such as SCID-II. Conducting further studies with gold standard instruments such as SCID-II and a control group is recom- mended. In addition, this study was clinic- based, and a field study may also be helpful to determine the comorbidity of personality disorders in less severe cases.


Personality disorders are common in patients with Gender Identity Disorder who are candidates for sex reassignment. As a result, the assessment of Personality disorders before sex reassignment surgery and offering psychological and medical intervention care, if needed, is strongly suggested. The results of this study also indicated that Borderline personality disorder is not necessarily the most comorbid personality disorder in patients with Gender Identity Disorder.




  1. Gender Identity Disorders. In: ed t, editor. Kaplan & Sadock’s Synopsis of Psychiatry: Behav- ioral Sciences/Clinical Psychiatry: Wolters Kluwer Health and Lippincott Williams & Wilkins; 2007. p. 718-26.
  2. Green R. Gender Identity Disorders. In: 9th, ed- itor. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry: Lippincott Williams & Wilkins; 2009. p. 2100-2.
  3. American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders.Text Revised (DSM-IV-TR). Forth Edition ed: American Psychiatry Association;
  4. Tsoi WF. The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988;78:501-4.
  5. Baker A, Van Kesteren PJ, Gooren LJ, Bezemer PD. The prevalence of transsexualism in the Nether- lands. Acta Psychiatr Scand. 1993; 87:237-8.
  6. Hoenig J, Kenna JC. The prevalence of trans- sexualism in England and Wales. Br J Psychiatry 1974;124:181-90.
  7. Ross MW, Walinder J, Lundstrom B, Thuwe I. Crosscultural approaches to transsexualism; a com- parison between Sweden and Australia. Acta Psy- chiatr Scand. 1981;63:75-82.
  8. Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder: Recommendations for the standards of care of the world professional associa- tion for transgender health. Int. J. Transgenderism. 2009;11:8–18.
  9. Mehrabi F. Study of some of characteristics of Iranian patients with Transsexualism. Andisheh va Raftar 1996;2:6-12.
  10. Murray JF. Borderline manifestations in the Rorschachs of male transsexuals. 1985;49:454-66.
  11. Lothstein LM. Psychological testing with transsexuals: a 30-year review. J Pers Assess. 1984; 48:500-7.
  12. Ahmadzad-Asl M, Jalali A.H, Alavi K, Naserbakht M,  Taban  M,  Mohseninia-Omrani


The Epidemiology of Transsexualism in Iran. Jour- nal of Gay & Lesbian Mental Health. 2010; 15(1).

  1. Beatrice J. A psychological comparison of heterosexuals, transvestites, preoperative transsexu- als, and postoperative transsexuals. J Nerv Ment Dis. 1985;173:358-65.
  2. Seikowski K,  Gollek  S,  Harth  W, Reinhardt
  3. Borderline personality disorder and Transsexual- ism. Psychiatr Prax. 2008; 35:135-41.
  4. Michel A, Ansseau M, Legros JJ, Pitchot W, Mormont C. The transsexual: what about the future? Eur Psychiatr. 2002;17:353-62.
  5. Bodlund O, G.K. Transsexualism – general outcome and prognostic factors: a five year follow- up study of nineteen transsexuals in the process of changing sex. Arch Sex Behav. 1996;25:303-16.
  6. Millon T. Millon CIinicul Multiaxiul Invento- ry (2nd ed.).Minneapolis, MN: Interpretive Scoring Systems.
  7. Millon T. The MCMI provides a good assess- ment of DSM-III disorders: the MCMI II will prove even better. Journal of Personality Assessment 1985; 49:379-91.
  8. McMahon R, Flynn P, Davidson R. Stability of the personality and symptom scales of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment. 1985;49:231L4.
  9. Khajeh Mugahi N, Baraheni MT, Mehrabi F. Preliminary preparation of Persian Version of Mil- lion Clinical Multiaxial Inventory in Tehran. Andisheh va Raftar. 1996; 2:68-9.
  10. Hepp U, Kraemer B, Schnyder U, Miller N, Del- signore Psychiatric comorbidity in gender identity disorder. J Psychosom Res 2005;58: 259-61.
  11. Haraldsen IR, Dahl AA. Symptom profiles of gender dysphoric patients of transsexual  type   com


Compared to patients with personality disorders and healthy adults. Acta Psychiatry Scand. 2000; 102:276-81.

  1. Roberto G. Issues in diagnosis and manage- ment of Transsexualism. Arch Sex Behav. 1983; 12:445-73.
  2. Bodlund O, Kullgren G, Sundbom E, Höjer- back T. Personality traits and disorders among transsexuals. Acta Psychiatry Scand. 1993; 88:322- 7.
  3. Levine SR. Psychiatric diagnosis of patients requesting sex reassignment surgery. Journal of Sexual and Marital Therapy. 1980;6(3):164–73.
  4. Choca JP, Shanley LA, Vondenberg Ei. Inter- pretative guide to The Millon clinical multiaxial inventory: American psychological Association USA
  5. Modestin J, Ebner G. Multiple personality dis- order manifesting itself under the mask of Transsex- ualism. Psychopathology. 1995;28:317-21.
  6. Craig robert J. psychological assessment with the Millon clinical Multiaxial inventory 11: An in- terpretive guide PAR;
  7. Theodore Millon. Journal of Personality As- sessment. 1985;49(4):379-91.
  8. Solds S, Budman S, Demby A, Merry J. Diag- nostic agreement between the personality disorder examination and the MCMI-II. Journal of Personali- ty Assessment. 1993;60(3): 486-99.
  9. Renneberg B, Chambless DL, Dowdall DJ, Fauerbach JA, Gracely EJ. The Structured Clinical Interview for DSM-III-R, Axis II and the Millon Clinical Multiaxial Inventory: A Concurrent Validi- ty Study of Personality Disorders among Anxious Outpatients. Journal of Personality Disorders. 1992;6(2):117-24.
Comments are closed.
%d bloggers like this: