Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style

J Sex Med. 2013 Dec;10(12):3049-58. doi: 10.1111/jsm.12155. Epub 2013 Apr 9.


Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic-pituitary-adrenal system dysregulation and subjective stress.

Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern.

Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers.

Main outcome measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self-reported perceived stress and the Adult Attachment Interview to determine attachment styles.

Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment.

Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Keywords: Adult Attachment; Cortisol Awakening Response; Gender Identity Disorder; Hormonal Sex-Reassignment Therapy; Perceived Stress; Transsexualism.

MeSH terms

  • Adolescent
  • Adult
  • Androgen Antagonists / therapeutic use
  • Androgens / therapeutic use
  • Anxiety / drug therapy*
  • Anxiety / etiology*
  • Cyproterone / therapeutic use
  • Estradiol / therapeutic use
  • Female
  • Gender Identity*
  • Hormones / therapeutic use*
  • Humans
  • Hydrocortisone / blood
  • Male
  • Middle Aged
  • Stress, Psychological / drug therapy*
  • Stress, Psychological / etiology*
  • Testosterone / therapeutic use
  • Transgender Persons / psychology*
  • Transsexualism / complications*
  • Transsexualism / psychology


  • Androgen Antagonists
  • Androgens
  • Hormones
  • Testosterone
  • Estradiol
  • Cyproterone
  • Hydrocortisone