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The International Journal of Transgenderism logoLink to The International Journal of Transgenderism
. 2018 Mar 20;20(1):108–117. doi: 10.1080/15532739.2018.1444529

Psychological symptoms and body image in individuals with gender dysphoria: A comparison between Iranian and Dutch clinics

Esmail Shirdel-Havar a,✉, Thomas D Steensma b,✉, Peggy T Cohen-Kettenis b, Baudewijntje P C Kreukels b
PMCID: PMC6831014  PMID: 32999598

ABSTRACT

Background: Few studies have compared the psychological functioning of individuals with gender dysphoria in Western and non-Western cultures. To our knowledge, this is the first study comparing the mental health of transgender individuals from an Islamic and non-Islamic country (Iran and the Netherlands).

Methods: In this study, the psychological functioning and body image of 163 individuals with gender dysphoria (100 transgender women (75 in the Netherlands, 25 in Iran) and 63 transgender men (45 in the Netherlands, 18 in Iran) in two clinics located in Iran (N = 43) and the Netherlands (N = 120) was evaluated using the SCL-90 and the Body Image Scale (BIS). Also, none of these individuals had yet received hormonal therapy and/or surgery in their clinics.

Results: Dutch participants (M = 31.56, SD = 12.26) were older than Iranian participants (M = 25.21, SD = 3.04). Dutch transwomen were less often androphilic (sexually attracted to men) than Iranian transwomen, and Iranian trans people were more often bisexual than the Dutch trans people. Significantly more Dutch transgender people were married (we had no information about the gender of the spouse), and indicated to have more contact with their families than the participants in Iran. The participants from Iran had significantly more psychological complaints than the Dutch participants. Compared to participants in Iran, participants in the Netherlands were more dissatisfied with their secondary sexual characteristics and neutral body characteristics, but there was no significant difference between the countries in terms of satisfaction with primary sex characteristics.

Conclusions: Although transgender people in many countries face social and mental health problems, this study suggests that socio-cultural factors may increase the likelihood of psychopathology.

KEYWORDS: Body image, cross-cultural, gender dysphoria, psychological function, transgender care

Introduction

Individuals with gender dysphoria (GD) suffer from an incongruence between their assigned gender and their experienced gender (American Psychiatric Association, 2013). This incongruence between gender identity and social role and/or the physical characteristics can cause distress and this may in turn lead to depression and anxiety (Heylens et al., 2014). In addition, depression and anxiety may be a consequence of negative attitudes towards GD in society and from transgender-related stigma (Owen-Smith et al., 2016; Yang, Manning, van den Berg, & Operario, 2015). So far, a fair number of studies have investigated the psychological functioning of transgender individuals. Mental health problems such as anxiety, and depression have been reported frequently (Dhejne, Van Vlerken, Heylens, & Arcelus, 2016; Haraldsen & Dahl, 2000; Millet, Longworth, & Arcelus, 2017; Shirdel-Havar, Yasrebi, Hassanzadeh, Moshkani, & Kaboosi, 2015; Zucker, Lawrence, & Kreukels, 2016).

Psychological problems may differ between countries and/or cultures, which may be related to the distress coming from attitudes of the environment towards transgender persons or access to appropriate care (Norton & Herek, 2012; Stotzer, 2009; Yousafzai & Bhutto, 2007). For instance, in a study comparing four countries (Belgium, Germany, the Netherlands and Norway) Axis I disorders (according to the DSM-IV-TR; APA, 2000) were more prevalent among transwomen in Germany and Norway than in Belgium and the Netherlands, although there was no significant difference between the four countries in the transmen (Heylens et al., 2014).

In Iran, like in many other countries, transgender people can be referred for treatment. If someone wants to apply for gender confirming treatment in Iran, he/she first has to go to a court and ask a judge for permission. In order to issue such a permission, the judge seeks the advice of one of 31 Legal Medicine Organizations (LMO; a governmental organization) to evaluate this person. The LMO, then, refers these persons to psychiatrists and endocrinologists and ask them to assess the applicant. With their report, the LMO interviews the person in a single session and determines a period of psychotherapy and social transition. These psychotherapies take place at transgender clinics or in private practices and usually last at least six months. At the end of this period the LMO advices the judge and the judge issues the legal permission for medical interventions. With that permission, the client can receive gender affirming medical treatment from any physician (governmental or private sector). Changing identity documents is only possible after surgical removal of gonads.

A study conducted in Iran indicates that, similar to many other countries, depression and anxiety disorders are highly prevalent in transgender people (Mazaheri Meybodi, Hajebi, & Ghanbari Jolfaei, 2014). Also, transwomen seem to suffer from more mental health problems than transmen (Ahmadzad-Asl et al., 2010).

Although individuals with GD receive financial and to some extent social support by the Iranian government, they are in many ways a neglected group. Interestingly, changing gender is not considered a sin in Islamic law and, as said before, it is legally allowed in Iran to undergo gender affirming medical treatment. In contrast, homosexuality, like murder, is considered to be a cardinal sin (Kariminia, 2000). Despite the legal situation, society and especially families (who often exercise a strong influence in the marriages of their children) and friends tend to reject transgender individuals. Usually they are discriminated, marginalized, and deprived from social rights, such as for example, marriage and employment (Javaheri & Kochakian, 2006). As one study in Iran showed, about one third of transgender individuals are unemployed (Kaldi, Tavassoli, & Hosseinian, 2009), which is similar to people with (Axis I) psychiatric disorders (33%), but much lower than the people from the general population (9,4%) (Rahimi-Movaghar et al., 2014).

Compared to Iran, the Dutch situation is relatively favorable. There are currently two academic gender identity clinics in the Netherlands and health care is financially covered. Also, the Netherlands, in contrast to Iran, is known as a country in which acceptance of gender variance is fairly widespread. Around 60 percent of the general public thinks that gender affirming treatment is a good idea if people have seriously considered it and less than 10% would end a friendship if the friend would appear to be transgender (Kuyper, 2012). Negative attitudes towards transgender people do not only exist in Iran, but in other countries as well. For instance, in a study from the US, 31% of transgender individuals report that they were not supported by their families and more than 37% of them reported violent acts by peers, teachers and school officials (Bradford, Reisner, Honnold, & Xavier, 2013). To our knowledge there have not been direct comparisons between the situation of transgender people in Iran and Western countries, but it may well be that the situation in Iran is even more disadvantageous than that of transgender individuals in Western countries. As a result of being rejected by their families and society, 65% contemplated suicide (Javaheri, 2010). Also, in Iran, family and social support, and economic resources play an important role in life-satisfaction of transgender individuals, but, because of the stigma and discrimination the satisfaction with life in this group is highly unfavorable (Khoshdel, & Talebian, 2015).

Most studies on psychological functioning of transgender people so far have been conducted within one clinic, one country or between countries with very similar cultures. We therefore wanted to compare applicants for treatment in both countries, wondering whether the difference in culture would result in different psychological complaints and/or in differences in severity of the complaints.

Another aim of this study was to explore the extent of gender dysphoria and body dissatisfaction of participants. So far, there have been no data about body dissatisfaction of people with gender dysphoria in Iran, and this is the first study to explore this issue.

Method

Participants

The Iranian participants were consecutively referred to a consultation clinic in Pooyan in 2014. The participants in Iran were seeking gender affirming medical treatment and were seen by a psychologist and psychiatrist. The Dutch participants were consecutively referred to the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam, the Netherlands, in 2010. For clinical procedures and data collection in the Amsterdam clinic we refer to Kreukels et al., 2012. During the diagnostic procedure clinical interviews were conducted by psychologists and psychiatrists. Both groups were invited to participate at the beginning of the clinical procedure. Of the 58 Iranian individuals invited to participate in the study, 15 declined. They did not want to participate in the study due to their personal circumstances. In the Dutch group all applicants for treatment agreed to participate. The samples under study included 43 individuals with GD (transwomen n = 25, transmen n = 18) in the clinic in Iran and 120 individuals with GD in the Dutch clinic (transwomen n = 75, transmen n = 45). None of them had yet received hormonal therapy and/or surgery in their clinics.

The study was approved by the Ethics Committee of the VU University Medical Center in Amsterdam, the Netherlands and by the Counseling Center of Sexual Disorders and Problems in Pooyan, Iran and all participants gave written informed consent.

Measures

The background interview

A demographic information questionnaire was used to collect data related to assigned sex, age, marital status, offspring and contact with family as well as sexual orientation (see Kreukels et al., 2012). Sexual orientation was assessed by the following question in the Background Interview “To whom do you feel sexually attracted.” Answers to this question were rated on a seven-point scale ranging from exclusively heterosexual (0) to exclusively homosexual (6) (Kinsey, Pomeroy, & Martin, 1948). According to their scores, the participants were classified in three sexual orientation categories: (1) Attracted to the other sex assigned at birth (Kinsey rating 0–1), (2) attracted to both sexes (Kinsey rating 2–4), and (3) attracted to same sex assigned at birth (Kinsey rating 5–6).

The Background interview as well as two questionnaires (UGDS and BIS) were translated into Persian by three psychologists and the translations were compared. Then, by another psychologist, the questionnaires were translated back into English. The translated versions were compared with the original version of the questionnaire and differences were discussed until agreement was reached.

Utrecht gender dysphoria scale (UGDS)

Gender dysphoria was measured by the Utrecht Gender Dysphoria Scale (UGDS) which is a questionnaire on which the subject rates his or her agreement on a 1–5 point scale. This questionnaire has 12 five-point Likert scale items. Its scores range from 12 to 60. This questionnaire has two versions, one for birth-assigned males one for birth-assigned females (Schneider et al., 2016). An example of an item is “I feel a continuous desire to be treated as a man/woman.” The higher the score the more intense the gender dysphoria (for psychometric data, see Schneider et al., 2016). For the Iranian UGDS the Cronbach's alpha's were .74−.96 for birth-assigned males and females respectively. Cronbach's alpha's for Dutch UGDS were .66−.92 (Schneider et al., 2016).

Body image scale (BIS)

The Body Image Scale (Lindgren & Pauly, 1975) was used to assess the person's satisfaction with their body parts. This scale consists of 30 body features. One can indicate dissatisfaction with each body part on a 5-point scale: 1 (very satisfied) to 5 (very dissatisfied). This questionnaire has two versions, one for birth-assigned males and one for birth-assigned females. Higher scores indicate higher dissatisfaction. Each of the 30 items falls into one of three groups of body features: primary sex characteristics, secondary sex characteristics, and neutral body characteristics. Both overall scores and subscale scores can be obtained from the BIS (e.g., van de Grift et al., 2016). For the Iranian BIS Cronbach's alpha's for birth-assigned females were .73 and for birth-assigned males were .60 and for the Dutch BIS Cronbach's alphas were .65 to .84.

Psychological symptoms

To assess the psychological symptoms of the participants in both clinics, the SCL-90-R (Symptom Checklist-90-R) was used (Anisi, Akbari, Madjian, Atashkar, & Ghorbani, 2011; Arrindell & Akkerman, 2004). This checklist assesses the current level of the symptoms which occur during a time period of one week. The purpose of the questionnaire is to carry out a fast assessment of the type and severity of the individual's symptoms through self-assessment and has 8 subscales, besides a total score (Anxiety, Agoraphobia, Depression, Somatization, Obsessive-Compulsive, Sensitivity, Hostility, and Sleeping Problems). We used the Dutch manual for analyzing SCL-90 data. Also, raw scores and mean item scores were used when testing for differences between countries (see Paap et al., 2012 for more information). Item scores range from 0 to 4 (none to severe) (Groth-Marnat, 2009). Cronbach's alpha's for the Iranian SCL-90 were .75 to .90 (Anisi et al., 2011). For the Dutch SCL-90, Cronbach's alpha's were .72 to .90 (Paap et al., 2012).

Statistical analyses

Using SPSS 16, differences between the Iranian and Dutch groups were calculated regarding age, extent of gender dysphoria, bodily dissatisfaction and psychological functioning by means of t-test, ANOVA, and Chi-square. To assess the difference between the participants in both countries regarding birth-assigned sex, marital status, offspring, contact with family and sexual orientation, Chi-square tests were used. Because we could not match the participants from both countries on demographic variables we first checked whether there were differences between the two countries (see Table 1 for demographic information and test-info on group differences). Age and marital status appeared to be significantly different. Both ANOVA's and ANCOVA's were performed, excluding or including age and marital status as covariates. No significant differences were observed between the ANOVA and ANCOVA findings. Therefore, we used ANOVA's to assess differences between the groups with the BIS primary sex characteristics, BIS secondary sex characteristics, BIS neutral body characteristics, and SCL-90-R total score and all subscale scores as dependent variables and birth-assigned sex as independent variables. Also, we used independent t-tests for the comparison of UGDS-scores.

Table 1.

Demographics of Iranian and Dutch participants (N = 163).

  Netherlands Iran χ2, t, p values
  n = 120 n = 43  
Sex      
 Transwomen (%) 75 (62.5) 25 (58.1) χ2 (1) = .254; p = ns
 Transmen (%) 45 (37.5) 18 (41.9)  
Age      
 Total M (SD) 31.56 (12.26) 25.21 (3.04) FCountry (1, 159) = 8.73, p = .004
 Transwomen M (SD) 34.08 (12.76) 25.32 (3.26) Fsex(1,159) = 3.49, p = ns
 Transmen M (SD) 27.36 (10.17) 25.06 (2.78) FCountryXSex(1,159) = 2.98, p = ns
Marital status      
 Single (%) 74 (64.3) 42 (97.7)  
 Partner/ married (%) 24 (20.9) 1 (2.3)  
 Other1 (%) 17 (14.8) 0 (0.0) χ2 (2) = 17.89; p < .001
Offspring      
 Yes 21 (17.6) 0 (0.0)  
 No 98 (82.4) 43 (100) χ2 (1) = 8.72; p = .003
Contact with family      
 Yes 111 (94.1) 31 (72.1)  
 No 7 (5.9) 12 (27.9) χ2 (1) = 14.62; p < .001
Sexual orientation      
Attracted to same sex as      
 birth-assigned sex 67 (61.5) 29 (67.4)  
 All 33 (44) 18 (72)  
 Transwomen / androphylic 34 (75.6) 11 (61.1)  
Transmen / gynephilic      
Attracted to both sexes      
 All 11 (10.1) 9 (20.9)  
 Transwomen 9 (12) 5 (20)  
 Transmen 2 (4.4) 4 (22.2)  
Attracted to the other sex as     χ2 (2) = 6.61; p = .037
birth-assigned sex      
 All 31 (27.4) 5 (11.6)  
 Transwomen /gynephilic 26 (34.7) 2 (8)  
 Transmen / andorphilic 5 (11.1) 3 (16.7)  
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1

Category ‘other’ included the answer option ‘divorced’ and an open-ended answer option ‘other’.

Results

Background variables

As can be seen in Table 1, the mean age of participants from the Dutch clinic was higher than the mean age of participants from the Iranian clinic. Differences in mean age between transmen and transwomen, or an interaction between country and assigned sex were not observed. Also, in the Netherlands, significantly more persons than in Iran were married or had a partner, and had offspring. Dutch participants also reported to have significantly more contact with the family.

Between the two countries there was a significant difference in the report of sexual orientation (See Table 1). Overall, transgender people in Iran reported significantly more often bisexuality than in the Netherlands (χ2 (1) = 6.64, p = .010). In transmen differences in sexual orientation between the two countries were not significant (p >.05), for transwomen a significant difference was observed (χ2 (2) = 7.94, p = .019). The percentage of Dutch transwomen reporting gynephylia was significantly higher compared to the transwomen in Iran (χ2 (1) = 7.58, p = .006).

UGDS and BIS: Gender incongruence

UGDS

For the UGDS a t-test between countries showed significant differences t (142.24) = −7.81, p < 0.001), showing higher GD scores in Iran than in the Netherlands. Analyzed separately for sex assigned at birth, GD scores for both sexes showed to be significantly higher in Iran than the Netherlands (transwomen: t (87.76) = −7.80, p < 0.001); transmen: t (52.63) = −3.16, p = 0.003). Also, see Table 2 for means and standard deviations of UGDS.

Table 2.

Dutch and Iranian participants' means and SDs on the UGDS and BIS (N = 163).

  Netherlands
 Iran
  Transwomen Transmen Total Transwomen Transmen Total
  (n = 75) (n = 45) (n = 120) (n = 25) (n = 18) (n = 43)
Variable M(SD) M(SD) M(SD) M(SD) M(SD) M(SD)
UGDS* 49.00 (8.23) 56.45 (3.15) 52.35 (7.49) 58.00 (1.76) 58.50 (1.82) 58.21 (1.78)
BIS Primary** 4.26 (0.57) 4.21 (0.55) 4.24 (0.56) 4.14 (0.37) 3.98 (0.35) 4.07 (0.37)
BIS Second** 3.25 (0.69) 3.15 (0.67) 3.22 (0.68) 1.99 (0.26) 2.40 (0.42) 2.17 (0.39)
BIS Neutral** 3.20 (0.68) 2.54 (0.54) 2.97 (0.71) 2.06 (0.21) 2.12 (0.28) 2.08 (0.24)
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*

Score range 12–60.

**

BIS primary = dissatisfaction with primary sex characteristics; BIS secondary = dissatisfaction with secondary sex characteristics; BIS neutral = dissatisfaction with neutral body characteristics. Higher scores represent higher degrees of body dissatisfaction, ranging from 1 = very satisfied, 5 = very dissatisfied.

BIS

With regard to primary sex characteristics, no significant main or interaction effects were found. Individuals with gender dysphoria in both countries were equally dissatisfied with their primary sex characteristics (see Table 2 for means and standard deviations of BIS). However, for secondary sex characteristics we found an interaction effect of country by birth-assigned sex indicating more dissatisfaction with secondary sex characteristics among transwomen than transmen in Iran F(1, 153) = 5.21, p = 0.024), but not in the Netherlands. A significant effect for country was also found F(1, 153) = 81.03, p < 0.001), with Dutch participants reporting more dissatisfaction than Iranian participants.

Regarding neutral body characteristics, we found a main effect of country, F(1, 153) = 59.05, p < 0.001), and assigned sex F(1, 153) = 8.69, p = 0.004), and a country by assigned sex interaction F(1, 153) = 12.27, p = 0.001). There was more dissatisfaction with neutral body parts in the Netherlands than in Iran. Transwomen were in general more dissatisfied than transmen in the Netherlands but not in Iran.

Psychological functioning

On the SCL-90 total scores, a 2 (country) × 2 (assigned sex) ANOVA yielded a significant main effect for country F(1, 145) = 45.78, p < 0.001) (see Table 3 for means and standard deviations). The results of the analysis indicated that the SCL-90 score was significantly higher in Iranian than in Dutch individuals with GD. There was no significant effect for assigned sex nor an interaction between country and assigned sex.

Table 3.

SCL-90-R means and standard deviations of Dutch and Iranian participants (N = 163).

  Netherlands
 Iran
  Trans Transmen Total Trans Transmen Total
  women     women    
  (n = 75) (n = 45) (n = 120) (n = 25) (n = 18) (n = 43)
Variable M(SD) M(SD) M(SD) M(SD) M(SD) M(SD)
SCL-90-Total 0.43 (0.48) 0.39 (0.29) 0.41 (0.42) 1.00 (0.49) 0.89 (0.49) 0.95 (0.49)
Anxiety 0.33 (0.49) 0.29 (0.28) 0.31 (0.42) 1.89 (0.74) 1.48 (0.80) 1.72 (0.78)
Agoraphobia 0.25 (0.46) 0.18 (0.31) 0.23 (0.41) 0.86 (0.80) 0.31 (0.43) 0.63 (0.72)
Depression 0.61 (0.63) 0.45 (0.39) 0.55 (0.55) 1.04 (0.91) 1.01 (0.93) 1.03 (0.91)
Somatization 0.32 (0.43) 0.35 (0.32) 0.33 (0.39) 1.10 (0.76) 1.23 (0.74) 1.15 (0.75)
Obsessive compulsive 0.59 (0.66) 0.59 (0.48) 0.59 (0.59) 0.98 (0.72) 1.20 (0.74) 1.07 (0.73)
Sensitivity 0.46 (0.58) 0.39 (0.40) 0.43 (0.52) 0.80 (0.60) 0.60 (0.36) 0.72 (0.52)
Hostility 0.23 (0.47) 0.25 (0.31) 0.24 (0.42) 0.56 (0.49) 0.50 (0.49) 0.53 (0.46)
Sleep problems 0.67 (0.78) 0.66 (0.74) 0.66 (0.76) 1.11 (0.54) 1.10 (0.79) 1.10 (0.65)
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Regarding the subscales, there was a significant difference in Anxiety between the two clinics F(1, 145) = 189.22, p < 0.001) as well as between the assigned sexes F(1, 145) = 4.85, p = 0.029). It showed a higher report of Anxiety in Iran than in the Netherlands, and a higher report in transwomen than in transmen. No significant interaction between assigned sex and country was observed.

There was also a significant difference in the Agoraphobia scores between the two countries F(1, 145) = 16.06, p < 0.001), i.e. Agoraphobia scores among the transgender individuals in Iran were higher than in the Netherlands. Also, transwomen in general had a higher score compared to transmen F(1, 145) = 11.48, p = 0.001). An interaction was found between country and assigned sex for the report of Agoraphobia F(1, 145) = 7.00, p = 0.009), showing that transwomen in Iran had significantly higher Agoraphobia scores than transmen in Iran, whereas no significant difference was observed between the groups in the Netherlands.

Furthermore, significant main effects for country were found in scores of Depression F(1, 145) = 15.95, p < 0.001), Somatization F(1, 145) = 75.59, p < 0.001), Obsessive-Compulsive F(1, 145) = 18.06, p < 0.001), Interpersonal Sensitivity F(1, 145) = 8.25, p < 0.001), Hostility F(1, 145) = 12.98, p < 0.001) and Sleeping Problems F(1, 145) = 10.41, p = 0.002). The mean scores of all these scales were higher among the Iranian participants than the Dutch participants. For these scales, no main effects for assigned sex nor interaction effects (assigned sex × country) were observed.

Discussion

In this first study directly comparing transgender individuals attending a Western European and an Iranian clinic, we found that Iranian individuals applying for gender affirming treatment have higher gender dysphoria scores than their Dutch counterparts. In both countries participants were equally dissatisfied with their primary sex characteristics. However, transmen were more dissatisfied with their secondary sex characteristics than transwomen in Iran but not in the Netherlands, and transwomen were more dissatisfied with neutral sex characteristics than transmen in the Netherlands but not in Iran. We also found that the Iranian participants were psychologically doing worse compared with the Dutch participants. In most areas of psychological functioning the Iranians of both birth-assigned sexes had more complaints than the Dutch participants; only with regards to agoraphobia, Iranian transwomen were scoring significantly higher than transmen, whereas no significant differences were found between transwomen and transmen in the Netherlands. In both countries transwomen were more anxious than transmen.

The higher gender dysphoria scores in Iran suggest that the incongruence between their experienced and assigned gender is associated with more distress. One wonders whether this is intrinsic to the gender incongruence in this particular group or the result of its societal consequences. The absence of differences between the groups in dissatisfaction with primary sex characteristics, suggests the latter. It is not clear why the Dutch were more dissatisfied with their secondary sex characteristics than the Iranians. The fact that they (transwomen in particular) were also rather dissatisfied with neutral body parts may indicate that the Dutch group has higher demands or higher expectations with regard to the possibilities of the medical interventions. The finding that only in Iran transmen were less happy with their secondary sex characteristics than transwomen is surprising. Taking the high agoraphobia score of the Iranian transwomen into account it is conceivable that they avoid social situations to a greater extent than transmen. By hiding themselves it might be easier to ‘deal’ with the visibility of their secondary sex characteristics. Therefore, transmen might be more exposed to negative responses of others to their physical appearance.

Considering the much higher total SCL-90-R scores in Iran than in the Netherlands it is not surprising that the scores on sub-scales Anxiety, Depression, Somatization, Obsessive-Compulsive, Sensitivity, Hostility and Sleeping Problems were all higher among the Iranian participants than among the Dutch participants. It is possible that this just reflects a poorer mental health situation in the general Iranian population. However, this explanation would not correspond with prevalence studies reporting similar rates (about 23%) of current psychiatric disorders in the general population of the two countries (Bijl, Ravelli, & van Zessen, 1998; Sharifi et al., 2015). Unfortunately, we did not have control groups of clinically referred psychiatric patients. It is therefore possible that persons with mental health problems in Iran are in general doing worse than in the Netherlands. Yet, transgender people are often without support, discriminated against, arrested by the police and other security agencies, rejected by family and friends, and victimized (Javaheri & Kochakian, 2006). One reason may be that homosexuality, which is very much looked down upon, is confused with being transgender (Arbatani, Aqili, Labafi, & Omidi, 2016). This may not only lead to physical dangers, financial problems and unemployment (American Psychiatric Association, 2013; Bariola et al., 2015; Javaheri, 2010; Khoshnood, Hashemian, Moshtagh, Eftekahri, & Setayesh, 2008; Kidd & Witten, 2007; Movahed & Hosienzadeh, 2011; Saeidzadeh, 2015; Stotzer, 2009), but to serious mental health problems as well (Budge, Adelson, & Howard, 2013; Klein & Golub, 2016; Reisner et al., 2016) and anxiety in particular (Aghabikloo, Bahrami, Saberi, & Emamhadi, 2013; Asgri, Saberi, Rezayi, & Dolatshahi, 2007; Dhejne, Van Vlerken, Heylens, & Arcelus, 2016). Indeed, we found that significantly less Iranian participants had contact with their families and were involved in a relationship. Also, there are no anti-discrimination laws in Iran. The lack of social support along with more discrimination or victimization may therefore explain the reported country differences in psychological problems.

The very high score on Agoraphobia in Iranian transwomen is understandable because the male physical characteristics are and often remain more visible in transwoman than feminine characteristics in transman and in Iran this is truly more dangerous. Despite the fact that legally and religiously gender transition is not considered a crime, transwomen are facing more criticism and contempt than transmen (Aghabikloo et al., 2013; Javaheri & Hoseinzade, 2011).

Except for the differences in psychological complaints there were a few other interesting differences between the two groups. First, more Dutch transwomen than Iranian transwomen reported to be gynephilic. Our findings are in line with results from another study done in Iran in which 91.7% of transwomen reported a sexual attraction to birth assigned men (Alavi, Jalali, & Eftekhar, 2014) and one from the Netherlands reporting only 38.2% androphilia. In contrast the rates of gynephila in transmen were comparably high in this study as in the studies by Alavi et al. (2014) (96.3%) and Kreukels et al. (2012) (83.3%). Because, in Iran, homosexuality is a crime punishable by imprisonment, corporal punishment, or by execution, it is likely that transgender people do not want to report their actual sexual attraction and findings should be interpreted with caution. However, as the Dutch transwomen were older at admission and more often had a partner and children it is also possible that there were actually more people with late onset GD in the Dutch than in the Iranian group. We believe that this might be the case because people with late onset GD have been reported to seek treatment at a later age and are more often attracted to the other gender than their gender assigned at birth and hence married (e.g., Nieder et al., 2011).

In all countries, transgender people carry an extra burden, because without medical interventions they can often not live as they would like. However, in some places the weight is even heavier than in other places because of societal attitudes. Our findings may be explained by a less favorable situation in a country like Iran, where culture and perhaps religion make it extremely hard for transgender people to have a good quality of life.

Our study has some limitations. Our sample size is not large and the Iranian group comes from only one part of the country, so it may not be representative of the entire transgender population in Iran. Also, because of the small sample size studying specific effects of certain demographic background variables such as sexual orientation was hampered. Future studies should therefore aim for larger sample sizes to increase our understanding of the differences between the two countries. Secondly, we could not compare our participants directly with clinical controls to see if the findings were specific for the transgender clinical groups. Third, the Dutch data were collected a few years before the Iranian study started. Although this might be seen as a weakness of the study, we believe that this, in fact, makes the data more comparable than when more recent data from Amsterdam would have been used. Since 2013 there has been a considerable increase in Dutch referrals which was accompanied by about 30% of “non-classical” treatment requests (Beek, Kreukels, Cohen-Kettenis, & Steensma, 2015). This could be partial treatment (e.g., no hormones or no or only some surgery), atypical dosages of hormones or an atypical order of interventions. It is therefore likely that the more recent Dutch referrals are more heterogeneous and less similar to the Iranian group, than when more recent referrals would have been included.

Conclusions

This is the first study comparing the mental health of transgender applicants for gender confirming treatment in a Western and a Muslim country. Our study confirmed studies from other countries reporting mental health problems in transgender people. Our findings on differences between the countries might be related to legal and religious differences and perhaps also differences in attitudes of the public. However, in order to draw more definite conclusions about the influence of environmental factors on the mental health of transgender people in other than Western cultures, further studies measuring these aspects directly are needed.

Declaration of conflict of interest

The authors have no conflict of interest to declare.

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