2976

ORIGINAL RESEARCH—TRANSGENDER AND

GENDER NONCONFORMANCE

Social Support and Psychological Well-Being in Gender

Dysphoria: A Comparison of Patients With Matched Controls

Amanda Davey, BSc,* Walter P. Bouman, MD, FRCPsych,† Jon Arcelus, MD, FRCPsych, PhD,*‡ and
Caroline Meyer, PhD*
*Centre for Research Into Eating Disorders, School of Sport, Exercise and Health Sciences, Loughborough University,
Loughborough, UK; †Nottingham Gender Clinic, Mandala Centre, Nottingham, UK; ‡Eating Disorders Service, Bennion
Centre, Leicester Glenfield Hospital, Leicester, UK

DOI: 10.1111/jsm.12681

ABSTRACT

Introduction. There is a paucity of research in the area of social support and psychological well-being among people
with gender dysphoria.
Aims. The present study aimed to investigate levels of social support among individuals with gender dysphoria
compared with a matched control group. It also aimed to examine the relationship between social support and
psychological well-being.
Methods. Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attend-
ing a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social
networking websites.
Main Outcome Measures. All participants completed measures of social support (Multidimensional Scale of Per-
ceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form
36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI).
Results. Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control
women, although these differences in levels of social support were no longer significant when SCL depression was
controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not
significantly predict SCL subscales but did predict both SF subscales and PWI total scores.
Conclusions. Trans women perceived themselves to be lacking social support. Given that social support is beneficial
to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings
have been derived from correlational results, extended research may highlight the value of clinicians helping trans
women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge
attitudes of nontrans people towards those with gender dysphoria. Davey A, Bouman WP, Arcelus J, and Meyer
C. Social support and psychological well-being in gender dysphoria: A comparison of patients with matched
controls. J Sex Med 2014;11:2976–2985.
Key Words. Gender Dysphoria; Transsexualism; Transgender; Social Support; Psychological Well-Being; Depression

Introduction well-being in terms of both psychological health

and life satisfaction. Specifically, a considerable

P sychological well-being is a multifaceted con-

struct that encompasses affective aspects of
personal experience [1]. Individuals with gender
dysphoria experience compromised psychological
number experience mental health difficulties [2,3],
with more than half reporting clinically depressive
symptoms [4]. For instance, one clinical study
reports that 80% of trans women and 55% of trans

J Sex Med 2014;11:2976–2985 © 2014 International Society for Sexual Medicine

Social Support in Gender Dysphoria
men with gender dysphoria have a history of
mental illness [3]. Similarly, prevalence rates of
attempted suicide in this population, at 32%, are
worryingly high [5]. This may be explained by the
fact that those with gender dysphoria are fre-
quently exposed to gender-based prejudice and
discrimination [5–7], which has been associated
with an increased risk of depression [4,8] and
diminished life satisfaction [9]. Given these
elevated risks, it is important to elucidate factors
that might potentially increase psychological well-
being in this group.
There are several factors known to affect psy-
chological well-being in the general population,
including levels of self-esteem, problem-solving
coping strategies, and social support [7,8]. Social
support is defined as the provision of resources
from others that are perceived to be beneficial to
the recipient [10]. Being socially connected and
supported has been found to have a positive effect
on self-esteem, mood, perceived control, and
coping behaviors in the general population
[8,11]. Conversely, a lack of social support is asso-
ciated with an increased vulnerability to mental
health problems, such as depression, suicidality,
and eating psychopathology [8,10–13]. Recent
research has highlighted some of the benefits of
social support, specifically among individuals with
gender dysphoria. For example, social support has
been linked with lower levels of both depression
and anxiety [8,14] and fewer suicidal behaviors
[15]. In addition, social support has been positively
associated with self-esteem [16] and quality of life
[14] among individuals with gender dysphoria and
is considered a predictor of psychological func-
tioning following sex reassignment surgery (SRS)
[17].
While social support may be beneficial in many
ways [13], it is often limited among those with
gender dysphoria. For example, compared with
their siblings, specifically their sisters, individuals
with gender dysphoria perceived less social
support from their families [18]. In fact, outright
rejection from families is not uncommon, particu-
larly when individuals first disclose their gender
identity [19]. In addition to a lack of familial
support, support from friends may also be limited.
For instance, Tully [20] describes a tendency
among treatment-seeking individuals to avoid
making new friends until SRS has been completed.
Consequently, post-treatment, they may face a
challenging new life with few existing support
resources readily accessible. One plausible theo-
retical model explaining limited support networks
2977
in this population is that the stigma surrounding a
trans identity may impair an individual’s ability to
form and maintain relationships [21]. An alterna-
tive explanation is that reduced social support may
be linked to the high levels of depression observed
in this population [4,8], given that depression is
typically associated with social withdrawal [22].
However, not all research suggests a lack of social
support. For example, Erich et al. [16] reports that
the majority (78%) of transgender individuals rate
support from family members positively.
While the term “gender dysphoria” denotes a
dissonance between a person’s gender and pheno-
type, individuals’ experiences of dysphoria can
vary considerably, and as such, heterogeneous
samples are often apparent in the literature. Addi-
tional inadequacies of previous studies include that
they have primarily recruited self-identified,
rather than clinically identified, transgender indi-
viduals and typically lack control groups. Trans
women, as a group, tend to be researched indepen-
dently [8,21], with far fewer attempts to study
trans men. In studies where both trans women and
trans men are invited to participate, gender differ-
ences are rarely distinguished. The only study to
separate trans women and trans men reported
similar levels of social support from family and
friends across the two groups [18]. Therefore, it
remains unclear as to whether levels of social
support differ specifically between the general
population and clinically diagnosed, treatment-
seeking trans women and men.
Aims
The global aim of this research was to examine a
potential theoretical model whereby gender dys-
phoria is linked with low levels of perceived social
support and where such a lack of support is linked
with decreased psychological well-being. There
were four objectives and associated hypotheses.
The first objective was to examine whether
individuals with gender dysphoria perceive differ-
ent levels of social support compared with an age-
and gender-matched control sample. In this
instance, the focus was on individuals’ perceptions
of, rather than actual, social support, though the
two are often conflated in the literature. In
keeping with the nonclinical findings of Factor and
Rothblum [18], hypothesis 1 predicted that indi-
viduals with gender dysphoria feel significantly
less socially supported compared with matched
controls.
J Sex Med 2014;11:2976–2985
2978
The second objective was to identify differences
in perceived social support across gender groups:
trans women, trans men, control women, and
control men. Given that trans women are met with
more intense social disapproval than trans men
[23], hypothesis 2 predicted that trans women per-
ceive significantly less social support than trans
men.
The third objective was to investigate whether
individuals with gender dysphoria significantly
differ from controls on psychological well-being
variables. Hypothesis 3 predicted that individuals
with gender dysphoria would report significantly
higher psychopathology and significantly lower
quality of life and life satisfaction than controls.
The fourth objective was to investigate whether
perceived social support predicts psychological
well-being. In line with well-being literature on
individuals without gender dysphoria, hypothesis 4
predicted that greater social support would signifi-
cantly predict better psychological well-being.
Given the relationship between depression and
social support [10], when differences in levels of
social support in hypotheses 1 and 2 were tested,
levels of depression were controlled for.
Methods
Participants
There were two groups of participants: a clinical
sample of individuals with gender dysphoria and a
matched control sample.
Clinical Sample
The clinical sample comprised patients attending a
national gender identity clinic in the Midlands of
England. Participants were eligible to take part if
they had a diagnosis of gender dysphoria, catego-
rized as transsexualism under the International
Classification of Diseases 10 [24], and were aged 18
years or over. All participants were engaged in the
treatment pathway and at one of three phases:
assessment, real-life experience (RLE), or post-
surgery. Assessment comprises psychological and
psychiatric evaluation spanning several months.
The RLE is a typically 2-year period where indi-
viduals enter full social and occupational adaptation
to their chosen gender role, commence hormone
therapy, and make documentary changes to articles,
such as their driving license. “Post-surgery” applies
to individuals who have undergone the RLE and at
least one gender reassignment surgical procedure.
Approximately 275 questionnaire packs were
J Sex Med 2014;11:2976–2985
Davey et al.
offered, of which 103 were returned fully com-
pleted. Sixty-three participants identified them-
selves as women, and 40 identified themselves as
men. The mean age was 36.4 years (SD 15.22), and
age range was 18 to 72 years.
Control Sample
An opportunity sample of nonclinical participants
was recruited via a university campus, local
businesses/organizations, and social networking
websites. The nonclinical sample was comprised of
adults who identified themselves as not having
gender dysphoria or being transgender. The
female-to-male ratio was also 63:40 as a result of
matching the two groups according to gender
identity (not birth sex). The mean age was 37.48
(SD 15.29), and age range was 18 to 73 years,
which was not significantly different from the
clinical sample (U = 5,044.5, P = 0.312). Further
demographic information is presented in Table 1.
Procedure
Ethical approval was granted from a National
Health Service research ethics committee and a
university institutional ethics board. Informed
consent was obtained from all participants.
For the clinical sample, clinicians identified and
subsequently distributed questionnaire packs to
eligible patients in person after their nearest
appointment. Each questionnaire pack contained
an information sheet, a consent form, a sociode-
mographic questionnaire, and several self-report
measures (in the order presented below). Partici-
pants completed the questionnaire pack at home
and mailed it back to the clinic using a prepaid
envelope. Data were collected over the course of
11 months. One hundred nine participants
returned questionnaires, producing a response rate
of 39.6%; however, six were subsequently dis-
counted due to substantial missing data.
Nonclinical participants were e-mailed or mes-
saged via social networking websites with a
weblink to an online survey identical to the ques-
tionnaire pack completed by clinical participants
and encouraged to forward the weblink to others.
A total of 160 nonclinical participants completed
the online survey, from whom 103 were selected
on the basis of age and gender identity to enable
matching with the clinical sample. Each clinical
participant was paired with a control participant of
the same gender identity and an age as close as
possible. A subsequent analysis was performed to
Social Support in Gender Dysphoria 2979

Table 1 Demographic characteristics of the clinical and control samples

Clinical sample Control sample Trans women Trans men Control women Control men
N = 103 N = 103 N = 63 N = 40 N = 63 N = 40
Mean age (years) 36.35 37.48 56.9 28.05 40.37 32.93
Ethnic origin
White 92 (89.3) 98 (95.1) 62 (98.4) 30 (75) 58 (92.1) 40 (100)
Indian 0 (0.0) 1 (1.0) 0 (0) 0 (0) 1 (1.6) 0 (0)
Black/other 1 (1.0) 0 (0.0) 0 (0) 1 (2.5) 0 (0) 0 (0)
Pakistani 1 (1.0) 0 (0.0) 0 (0) 1 (2.5) 0 (0) 0 (0)
Chinese 1 (1.0) 0 (0.0) 1 (1.6) 0 (0) 0 (0) 0 (0)
Other 8 (7.8) 4 (3.9) 0 (0) 8 (20) 4 (6.3) 0 (0)
Employment status
Employed full-time 42 (40.8) 37 (35.9) 26 (41.3) 16 (40) 21 (33.3) 16 (40)
Employed part-time 4 (3.9) 19 (18.4) 2 (3.2) 2 (5) 18 (28.6) 1 (2.5)
Student 15 (14.6) 35 (34) 5 (7.9) 10 (25) 17 (27) 18 (45)
Volunteer work 10 (9.7) 4 (3.9) 3 (4.8) 7 (17.5) 2 (3.2) 2 (5)
Housewife/househusband 0 (0) 0 (0) 0 (0) 0 (0) 2 (3.2) 0 (0)
Disabled 3 (2.9) 2 (1.9) 1 (1.6) 2 (5) 0 (0) 0 (0)
Unemployed 13 (12.6) 1 (1) 10 (15.9) 3 (7.5) 1 (1.6) 0 (0)
Other 16 (15.5) 5 (4.9) 16 (25.4) 0 (0) 2 (3.2) 3 (7.5)
Civil status
Single, never married 71 (68.9) 52 (50.5) 36 (57.1) 35 (87.5) 25 (39.7) 27 (67.5)
Married 8 (7.8) 35 (34) 6 (9.5) 2 (5) 27 (42.9) 8 (20)
Civil partnership 1 (1) 3 (2.9) 0 (0) 1 (2.5) 1 (1.6) 2 (5)
Separated 3 (2.9) 3 (2.9) 1 (1.6) 2 (5) 2 (3.2) 1 (2.5)
Divorced 15 (14.6) 4 (3.9) 15 (23.8) 0 (0) 4 (6.3) 0 (0)
Widowed 2 (1.9) 3 (2.9) 2 (3.2) 0 (0) 3 (4.8) 0 (0)
Other 1 (1) 1 (1) 1 (1.6) 0 (0) 1 (1.6) 0 (0)
Living situation
With family of origin 29 (28.2) 13 (12.6) 13 (20.6) 16 (40) 7 (11.1) 6 (15)
Alone 34 (33) 21 (20.4) 27 (42.9) 7 (17.5) 12 (19) 9 (22.5)
Shares with nonpartner 15 (14.6) 10 (9.7) 7 (11.1) 8 (20) 2 (3.2) 8 (20)
With partner only 15 (14.6) 25 (24.3) 8 (12.7) 7 (17.5) 15 (23.8) 10 (25)
With partner and children 3 (2.9) 24 (23.3) 3 (4.8) 0 (0) 19 (30.2) 5 (12.5)
With children only 2 (1.9) 4 (3.9) 2 (3.2) 0 (0) 4 (6.3) 0 (0)
Other 5 (4.9) 5 (4.9) 3 (4.8) 2 (5) 3 (4.8) 2 (5)
Treatment stage
Assessment 7 (6.8) — 4 (6.3) 3 (7.5) — —
Real-life experience 78 (75.7) — 47 (74.6) 31 (77.5) — —
Post-surgery 17 (16.5) — 11 (17.5) 6 (15) — —
Hormone status
No use 19 (18.5) — 11 (17.5) 0 (0) — —
Current use 81 (78.6) — 50 (79.4) 0 (0) — —
Previous use 1 (1) — 1 (1.6) 0 (0) — —

All data given as n (%) except for age.

ensure the mean ages of the two groups were not 28]. It has also been used in transgender popula-
significantly different. tions [14]. For these data, the Cronbach’s alpha
was 0.93.

Main Outcome Measures

Multidimensional Scale of Perceived Social Support
The Multidimensional Scale of Perceived Social
Support (MSPSS) [25] measures perceived social
support. It comprises three subscales: family
support, friend support, and support from a sig-
nificant other. All 12 items are rated on a scale
from 1 to 7. A total mean score and mean subscale
scores are calculated, with higher scores indicating
greater perceived support. The MSPSS has been
used with diverse samples and has consistently
demonstrated good psychometric properties [26–
Symptom Checklist 90 Revised
Psychopathology was measured using the
Symptom Checklist 90 Revised (SCL-90-R) [29].
The SCL-90-R contains 90 items divided into
nine primary symptom dimensions (somatization,
obsessive–compulsive, interpersonal sensitivity,
depression, anxiety, hostility, phobic anxiety, para-
noid ideation, and psychoneuroticism). Scores, on
a five-point Likert scale, indicate how much a par-
ticular problem has distressed the respondent
during the previous 7 days, with higher scores
indicating greater distress. The total mean score,

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2980
the Global Severity Index (GSI), indicates overall
psychological distress. The instrument demon-
strates good construct validity and reliability
across a multitude of samples and populations [30].
It has also been used widely across the transgender
literature [31–35]. In this study, the Cronbach’s
alpha was 0.97.
Short-Form Health Survey 36 Version 2
The Short-Form Health Survey 36 (SF-36) [36]
measures functional quality of life, with higher
scores indicating greater perceived quality of life.
Calculating the mean of four subscales (vitality,
social functioning, role limitations due to emo-
tional problems, and mental health) produces a
mental health component summary score. This
scoring format, set out by the measure’s authors,
has been used previously in transgender research
[37]. Subscales relating to physical health were
considered not relevant to this study. Internal reli-
ability and discriminant validity are reportedly
high [38]. The Cronbach’s alpha here was 0.93.
Personal Wellbeing Index
The Personal Wellbeing Index (PWI) [39] mea-
sures life satisfaction across eight domain items,
including standard of living, achievements in life,
personal relationships, personal safety, community
connectedness, future security, and spirituality/
religion. A mean total score is calculated, with
higher scores indicating greater life satisfaction.
Although it has not yet been validated in clinical
samples, the PWI is psychometrically sound in
nonclinical samples, demonstrating good reliabil-
ity, validity, and sensitivity across culturally diverse
populations [40]. Here, the Cronbach’s alpha was
0.88.
Data Analysis
The data did not meet the assumptions of normal
distribution (for instance, the Kolmogorov–
Smirnov test on total MSPSS was significant at
D[206] = 0.107, P < 0.000); therefore, nonpara-
metric tests were employed. To test hypothesis 1,
one-tailed Mann–Whitney U-tests were per-
formed to compare the clinical and control groups’
MSPSS scores. To test hypothesis 2, one-tailed
Kruskal–Wallis tests were conducted to examine
differences between trans women, trans men,
control women, and control men. Where there
were significant results, post hoc one-way analyses
of covariance (ANCOVAs) were performed to
control for participants’ scores on the SCL depres-
sion subscale. To test hypothesis 3, one tailed
J Sex Med 2014;11:2976–2985
Davey et al.
Mann–Whitney U-tests were used to compare the
clinical and control groups’ SCL, SF, and PWI
scores. Data were bootstrapped in these analyses.
For hypothesis 4, multiple regression analyses
using the enter method were performed to test
whether MSPSS subscales were significant predic-
tors of SCL GSI and SCL subscales, SF mental
health component summary score and SF
subscales, and PWI total. An alpha level of 0.01
was used to determine significance.
Results
Perceived Social Support Among the Clinical and
Control Groups
The clinical group reported significantly lower
scores on MSPSS total and all MSPSS subscales
compared with the control group (see Table 2).
The effect sizes were as follows: 0.47 MSPSS total,
0.51 MSPSS family, 0.34 MSPSS friends, and 0.26
MSPSS significant other. However, when analyzed
by gender, trans men did not score significantly
differently to trans women or either control group
on MSPSS total or any MSPSS subscales. In con-
trast, trans women scored significantly lower on
MSPSS total (Z = 16.84, P = 0.001) and MSPSS
family (Z = 14.76, P = 0.002) compared with
control women, but not control men. When con-
trolling for SCL depression, differences between
the clinical and control groups in MSPSS total
remained significant, whereas differences in all
three MSPSS subscales became nonsignificant (see
Table 2). Furthermore, differences between trans
women and control women in MSPSS total and
MSPSS family also became nonsignificant (respec-
tively: F = 1.99, P = 0.117; F = 2.26, P = 0.082).
Comparison of Psychological Well-Being Between the
Clinical and Control Groups
In comparison with the control group, the clinical
group scored significantly higher on SCL GSI and
SCL subscales (see Table 2). The clinical group
also scored significantly lower on all SF subscales,
with the exception of SF vitality and PWI total,
than the control group.
Perceived Social Support as a Predictor of
Psychological Well-Being
In relation to psychopathology in the clinical
sample, MSPSS subscales were only found to sig-
nificantly predict SCL somatization (F = 4.7,
P = 0.004), although there was a near-significant
result for SCL depression (F = 3.63, P = 0.016).
Social Support in Gender Dysphoria 2981

Table 2 Comparison of the clinical and control samples on each measure (N = 103)
Clinical sample Control sample Mann–Whitney U ANCOVA
Measure Mean (SD) Mean (SD) U P F P
MSPSS
Total score 5.03 (1.27) 5.64 (1.34) 3,650.0 <0.000** 6.86 0.01*
Family support 4.59 (1.95) 5.50 (1.62) 3,733.5 <0.000** 6.07 0.015
Friend support 5.23 (1.39) 5.68 (1.30) 4,120.0 0.0025* 1.59 0.209
Significant other support 5.28 (1.78) 5.72 (1.65) 4,379.0 0.013* 0.383 0.537
SCL-90-R
Global Severity Index 0.66 (0.55) 0.28 (0.32) 2,755.0 <0.000**
Somatization 0.53 (0.53) 0.30 (0.40) 3,784.0 <0.000**
Obsessive–compulsive 0.95 (0.83) 0.50 (0.58) 3,440.0 <0.000**
Interpersonal sensitivity 0.83 (0.76) 0.34 (0.45) 3,129.0 <0.000**
Depression 0.92 (0.75) 0.36 (0.49) 2,554.0 <0.000**
Anxiety 0.45 (0.53) 0.18 (0.36) 3,428.5 <0.000**
Hostility 0.46 (0.50) 0.24 (0.30) 3,909.0 0.0005**
Phobic anxiety 0.45 (0.66) 0.09 (0.26) 2,867.5 <0.000**
Paranoid ideation 0.65 (0.66) 0.24 (0.36) 3,261.0 <0.000**
Psychoneuroticism 0.45 (0.54) 0.12 (0.28) 2,794.0 <0.000**
SF-36 v. 2
Mental health component summary 69.31 (16.81) 76.73 (13.01) 3,855.5 0.005*
Vitality 54.38 (21.08) 59.63 (17.71) 4,447.5 0.022
Social functioning 77.46 (26.02) 89.98 (17.30) 3,745.0 <0.000**
Role limitations due to emotional problems 81.22 (22.97) 89.91 (17.96) 4,093.0 0.001**
Mental health 70.85 (17.27) 77.21 (14.99) 4,092.5 0.002*
PWI
Total score 63.23 (16.49) 71.77 (17.30) 3,352.5 <0.000**

Higher scores indicate greater social support (MSPSS), greater psychological distress (SCL-90-R), higher quality of life (SF-36 v. 2), and higher life satisfaction
(PWI)
*P < 0.01, **P < 0.001

Regarding quality of life, MSPSS subscales signifi- Discussion

cantly predicted SF mental health component
summary as well as SF vitality and SF mental
health (see Table 3). In terms of life satisfaction,
MSPSS subscales significantly predicted 22% of
the variance in PWI total.
The overarching aims of this paper were to deter-
mine differences in perceived social support
between individuals with gender dysphoria and
individuals without gender dysphoria and to assess

Table 3 Social support as a predictor of psychological well-being variables (N = 103)

Clinical Percent Significant Control Percent Significant

variance individual variance individual
Measure F P explained predictors F P explained predictors
SCL-90-R
Global Severity Index 2.735 0.048 8 — 0.93 0.429 3 —
Somatization 4.696 0.004** 13 Family* 0.153 0.928 1 —
Obsessive–compulsive 1.616 0.19 5 — 1.198 0.315 4 —
Interpersonal sensitivity 2.139 0.1 6 — 1.129 0.341 3 —
Depression 3.632 0.016 10 — 0.433 0.73 1 —
Anxiety 1.367 0.257 4 — 0.57 0.636 2 —
Hostility 0.915 0.437 3 — 0.287 0.835 1 —
Phobic anxiety 1.282 0.285 4 — 1.829 0.147 5 —
Paranoid ideation 2.039 0.113 6 — 4.841 0.003*
Psychoneuroticism 2.599 0.056 7 — 2.475 0.066 7 —
SF-36 v. 2
Mental health component summary 4.48 0.005* 12 — 2.52 0.062 7 —
Vitality 4.35 0.006* 12 Friends* 0.82 0.486 2 —
Social functioning 0.89 0.447 3 — 0.45 0.72 1 —
Role limitations due to emotional problems 2.61 0.055 7 — 3.98 0.01* 11 Friends*
Mental health 5.74 0.001* 15 — 2.583 0.058 7 —
PWI
Total score 9.11 <0.000** 22 Family* 6.85 <0.000** 18 —

*P < 0.01, **P < 0.001

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2982
whether perceived social support predicted psy-
chological well-being. Hypothesis 1 was sup-
ported: Individuals with gender dysphoria
reported significantly less perceived social support
than the control group. The second finding, that
trans women reported lower perceived social
support overall and from their families than
control women, offers partial support for hypoth-
esis 2. However, trans men did not significantly
differ from either trans women or controls. Indi-
viduals with gender dysphoria displayed signifi-
cantly higher psychopathology and lower quality
of life and life satisfaction compared with controls,
as predicted in hypothesis 3. Finally, perceived
social support was not a significant predictor of
psychopathology; however, it did predict quality of
life and life satisfaction, lending some support to
hypothesis 4.
Typical gender differences in seeking and utiliz-
ing social support might explain why trans women
experience less social support compared with
control women but not control men. Men are less
likely to seek social support compared with women
[41], a trend attributed to male socialization and
the perception that seeking social support is a
feminine behavior [42]. Having been socialized as
male from childhood, trans women may have less
developed support networks or may be more
restricted in seeking support than control women
who have continuously been socialized as female.
Additionally, general attitudes to femininity in
men are much less tolerant than attitudes to mas-
culinity in women [23]. While this has not been
considered in relation to families, it is plausible
that these differences in acceptance may extend to
family settings.
In comparison with friends and partners (some-
times referred to as families of choice), relation-
ship transitions may be more complicated among
families of origin. Families of origin may have
known the person longer in their sex assigned at
birth and thus may find adjustment, and conse-
quently being supportive, more difficult. Parents
especially can sometimes feel responsible for their
child’s gender dysphoria [43], and this may hinder
a fully supportive relationship. In contrast, it
would be expected that families of choice are
selected on the basis of support and love that is not
necessarily assured within families of origin and,
therefore, would demonstrate greater acceptance.
This explanation appears to be supported by the
finding that family support, as opposed to support
from friends and significant others, is lower among
trans women.
J Sex Med 2014;11:2976–2985
Davey et al.
When participants’ levels of depression were
taken into consideration, many of the differences
between the clinical and control group became
nonsignificant. This finding is not overly surpris-
ing, given the well-documented relationship
between depression and social support in the wider
literature [40,41]. For instance, depression is char-
acterized by social withdrawal and isolation [22].
In line with previous research [4], individuals with
gender dysphoria reported higher levels of depres-
sion than controls. Therefore, management of
depression in this population may benefit from an
approach aimed at increasing social support and
healthy interpersonal relationships. Future
research investigating interpersonal functioning in
this population may be valuable.
While perceived social support was a poor pre-
dictor of psychopathology, it did significantly
predict quality of life and life satisfaction, support-
ing similar findings by Erich et al. [16]. There are
two potential ways social support might benefit
psychological well-being in individuals with
gender dysphoria. It may have a direct effect on
well-being by its intrinsic value; for example, Moss
[44] describes social support as the subjective
feeling of being accepted and loved and belonging.
It may also, in line with Cohen’s stress-buffering
hypothesis [45], act indirectly as a buffer against
negative experiences, such as discrimination and
victimization. This has been highlighted in a non-
transgender sample where the association between
stigma and psychological functioning was medi-
ated by social support [46].
Limitations and Directions for Further Research
In this study, there are methodological limitations
that must be acknowledged. The patients in the
sample attended a UK gender identity clinic, so
the results cannot necessarily be applied to indi-
viduals outside the UK, those not seeking treat-
ment, or those who do not fulfill diagnostic
criteria. Regarding statistics, though the data were
not normally distributed, there is no nonparamet-
ric equivalent of regression; therefore, it is advised
that the results be interpreted with caution. Also,
differences were observed in the distribution of
clinical participants across certain sociodemo-
graphic variables, compared with nonclinical par-
ticipants. While only age and gender were
controlled, it should be acknowledged that
sociodemographics, such as employment and civil
status, are associated with well-being in the
nontrans literature and might be influenced by
gender dysphoria and its associated stigma. In
Social Support in Gender Dysphoria
terms of measures, a drawback of the MSPSS is
that it measures sources but not types of social
support. Social support can take various forms, for
instance emotional, instrumental, informational,
and appraisal support [47]. It is possible that indi-
viduals with gender dysphoria may need different
types of support through their gender journey. A
further limitation is that support from others who
identify as trans was not measured, though other
research suggests that support from transgender
communities is highly valued [48]. The unique
experiences shared by trans communities may
create a distinct source of support, as they can
provide instrumental support regarding self-
disclosure, “passing,” and ways to manage employ-
ers and government bureaucracies [49]. It is
possible that this source of support may have been
captured by friend support within the MSPSS;
however, it would be useful to explicitly measure
support from transgender others in future.
Recommended directions for further research
include investigation into the impact of stage of
treatment, actual received support, and mediating
factors. Unfortunately, due to the homogeneity
within the clinical sample, it was not possible to
test whether stage of treatment was associated with
perceived social support or whether social support
predicted psychological well-being more or less
strongly across the treatment trajectory. In other
research, one of the areas where improvements
following SRS were most notable was interper-
sonal relationships [50]. Therefore it would be
valuable for future research to examine the poten-
tial effects of stage of treatment and social transi-
tion. While this study examined subjective social
support, a next step could be to objectively evalu-
ate the support actually available, potentially by
quantifying social ties or network size. It is cur-
rently not known whether individuals with gender
dysphoria have interpersonal difficulties seeking
social support or whether others are less support-
ive towards them. One final suggestion for further
research is to explore potential mediators of the
relationship between perceived social support and
psychological well-being, such as interpersonal
functioning.
Conclusions
These findings signify the importance of assisting
individuals with gender dysphoria, particularly
trans women, to develop and utilize various
sources of social support, given the impact on
quality of life and life satisfaction. To improve
2983
family support, greater involvement of family
members in the treatment process is encouraged,
in keeping with recent clinical guidelines [51,52].
Family support is often lacking within gender
identity clinic services, and it has been highlighted
that individuals with gender dysphoria would like
support and help for their families in coping with a
relative experiencing gender dysphoria [53]. Clini-
cians, together with other health professionals, are
in a unique position to advocate for patients and
liaise with their families, perhaps breaking down
barriers of misunderstanding and fostering good
communication. In addition, efforts could be made
more broadly to educate and challenge attitudes of
nontrans people toward those with gender dys-
phoria, thereby encouraging empathy and sup-
portive responses.
Corresponding Author: Walter Pierre Bouman, MD,
FRCPsych, Nottingham Gender Clinic, Mandala
Centre, Gregory Boulevard, Nottingham NG7 6LB,
UK. Tel: +44 115 9602820; Fax: +44 115 9602843;
E-mail: walterbouman@doctors.org.uk
Conflict of Interest: The authors report no conflicts of
interest.
Statement of Authorship
Category 1
(a) Conception and Design
Amanda Davey; Walter P. Bouman; Jon Arcelus;
Caroline Meyer
(b) Acquisition of Data
Amanda Davey; Walter P. Bouman
(c) Analysis and Interpretation of Data
Amanda Davey; Jon Arcelus; Caroline Meyer
Category 2
(a) Drafting the Article
Amanda Davey; Walter P. Bouman; Jon Arcelus;
Caroline Meyer
(b) Revising It for Intellectual Content
Amanda Davey; Walter P. Bouman; Jon Arcelus;
Caroline Meyer
Category 3
(a) Final Approval of the Completed Article
Amanda Davey; Walter P. Bouman; Jon Arcelus;
Caroline Meyer
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