Paranoia in patients with gender dysphoria: A clinical exploration.

BACKGROUND: Gender identity disorder (GID) is a distressing disorder characterized by a persistent unhappiness with one's own gender and a desire to be of the opposite gender as well as seeking sex reassignment surgery for the same. The aim of the study was to assess the Minnesota Multiphasic Personality Inventory (MMPI) profiles in patients with GID and compare with healthy normal population and also examine differences in the profiles based on original gender of the patients.
MATERIALS AND METHODS: A total of 56 patients with GID that fulfilled the Diagnostic and Statistical Manual of Mental Disorders 5 criteria for the same were participants of the study, and there were 54 control participants. They were administered the MMPI, and the scores across various scales were statistically analyzed.
RESULTS: It was seen that apart from masculinity feminity (Mf) scale, other scales such as Paranoia (Pa, P < 0.01), Schizophrenia (Sc, P = 0.01), and Psychopathic deviate (Pd, P < 0.01) were also elevated in many patients. Male patients seeking surgery to become female showed higher scores on Pa and Sc scales than female patients. On detailed inquiry, it was found that there was no evidence of psychosis clinically, and in fact, their paranoia was reality based.
CONCLUSION: MMPI profiles in patients with GID needs to interpreted with caution and clinicians must keep in mind that elevated Pa and Sc scales on the MMPI in these patients need not indicate a psychotic profile. Copyright:

INTRODUCTION

Gender identity disorder (GID) is a distressing condition where there is a strong and persistent desire of wanting to belong to a gender opposite to what the patient is in, and there is a persistent request toward sex reassignment surgery for the same.[1] The patient often has a discomfort with his/her biological sex and seeks help via a psychiatric consultation to get a formal approval for sex reassignment surgery to look like the opposite sex.[2] GID often presents to the psychiatrist when referred from the plastic surgeon whom these patients approach for sex reassignment surgery. These patients often have comorbid psychopathology, anxiety, lack of parental and family support, and extreme psychological distress.[3] Some of them may directly present to the psychiatrist when brought by family members. A variety of psychological tests, rating scales, sex role inventories, projective tests, neuropsychological assessments, and psychopathology scales have been used in the assessment of individual with GID.[4] The Minnesota Multiphasic Personality Inventory (MMPI) has been used in many studies to understand psychopathology in patients with GID with varying results.[56]

The current study aims to study the MMPI profiles of patients suffering from GID and observe whether any particular patterns emerged when compared to normal controls and to elucidate any differences based on the original gender of the patient.

MATERIALS AND METHODS

The sample for the study consisted of 56 consecutive patients with GID that on clinical assessment met the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)[7] criteria for GID in adulthood and presented to the psychiatric outpatient department of our hospital with chief complaints of gender dysphoria and wanted to undergo sex reassignment surgery. All cases were assessed by two senior psychiatrists and one clinical psychologist to ensure that the DSM criteria were fulfilled and to confirm the diagnosis. The study involved an exploration of psychological testing reports from our department. The study did not involve any interview of live subjects. Keeping the same in mind, the study was discussed in a departmental review board meeting and clearance obtained for the same. The patients who underwent psychological testing had given informed written consent for use of their test records under anonymity for the purpose of this study which would be akin to a retrospective chart review. Data from these patients were collected over a 3 years period between January 2015 and January 2017. The control group comprised 54 clients who did not have any psychiatric complaints. This was assessed via a clinical interview by the same clinicians that assessed the GID patients.

The MMPI is a 566-item with statements that are used to assess personality, and the individual has to answer true or false based on how the statement applies to him/her. Its validity and reliability have been established. The inventory comprises three validity scales – Lie (L), Infrequency (F), and Correction (K) and ten clinical scales – Hypochondriasis (Hy), Depression (D), Hysteria (Hs), Psychopathic Deviate (Pd), Masculinity-Femininity (Mf), Paranoia (Pa), Psychasthenia (Ps), Schizophrenia (Sc), Mania (Ma), and Social Introversion (Si). This inventory is currently the most widely used questionnaire for systematic assessment of psychopathology. Raw scores are converted to uniform T scores relative to normative data using the norms corresponding to the biological sex. Scores of above 80 on the L, 100 on the F, and 70 on the K validity scales are suggestive of response distortion. Scores of 70 or above in the clinical scales were considered to be clinically significant.[8]

RESULTS

The mean age in patient group was 27.21 ± 4.6 years and in control group was 38.63 ± 9.2 years. In patient group, there were 36 male and 20 female, while in control group, there were 46 male and 8 female. On comparison across various scales, significant difference was seen in case and control groups in majority of scales such as Pd, Mf, Pa, Pt, Sc, and Ma [Table 1].

Table 1

Minnesota Multiphasic Personality Inventory scores across both groups in the study

Scale	Mean±SD		Student’s t-test
	Cases (n=56)	Control (n=54)	t	P
L	58.43±8.79	62.94±6.41	−3.06	0.003*
F	68.07±12.08	60.63±7.5	3.86	<0.01*
K	50.18±9.01	54.63±7.35	−2.83	0.006*
Hs	56.39±11.43	59.31±7.03	−1.6	0.11
D	59.02±12.41	57.76±6.82	0.65	0.51
Hy	55.73±11.61	55.15±7.82	0.30	0.75
Pd	65.16±11.28	56.37±9.14	4.47	<0.01*
Mf	78.21±7.36	58.04±9.29	12.64	<0.01*
Pa	67.54±13.14	60.13±7.33	3.63	<0.01*
Pt	57.46±13.10	52.14±6.22	2.70	0.008*
Sc	68.71±15.87	62.59±7.11	2.59	0.01*
Ma	64.41±9.88	58.11±7.15	3.81	<0.01*
Si	48.68±8.04	50.72±3.91	−1.68	0.09

*Significant (P < 0.05). SD – Standard deviation; L – Lie; F – Infrequency; K – Defensiveness; Hs – Hypochondriasis; D – Depression; Hy – Hysteria; Pd – Psychopathic deviate; Mf – Masculinity/femininity; Pa – Paranoia; Pt – Psychasthenia; Sc – Schizophrenia; Ma – Hypomania; Si – Social introversion

In GID cases, difference in scores across various scales was compared based on biological sex of the patient. As per Table 2, it was seen that male-to-female patients had more features of paranoia than female-to-male patients, and the difference was statistically significant.

Table 2

Minnesota multiphasic personality inventory scores in two groups made based on original gender in the gender identity disorder patients

Scale	Mean±SD		Student’s t-test
	Male-to-female patients (n=36)	Female-to-male patients (n=20)	t	P
L	59.58±9.63	56.35±6.76	1.32	0.19
F	70.92±11.39	62.95±11.86	2.47	0.01*
K	49.86±9.71	50.75±7.80	−0.35	0.72
Hs	57.61±11.55	54.20±11.18	1.07	0.28
D	61.11±13.11	55.25±10.29	1.72	0.09
Hy	57.78±11.26	52.05±11.59	1.80	0.07
Pd	65.89±10.23	63.85±13.15	0.64	0.52
Mf	77.50±7.42	79.50±7.27	−0.97	0.33
Pa	70.11±13.03	62.90±12.32	2.02	0.04*
Pt	60.08±13.7	52.75±10.74	2.06	0.04*
Sc	72.22±17.43	62.40±10.19	2.3	0.02*
Ma	64.78±10.07	63.75±9.74	0.37	0.71
Si	49.61±9.20	47.00±5.18	1.16	0.24

*Significant (P < 0.05). SD – Standard deviation; L – Lie; F – Infrequency; K – Defensiveness; Hs – Hypochondriasis; D – Depression; Hy – Hysteria; Pd – Psychopathic deviate; Mf – Masculinity/femininity; Pa – Paranoia; Pt – Psychasthenia; Sc – Schizophrenia; Ma – Hypomania; Si – Social introversion

Male patients opting for sex reassignment surgery to females had higher scores on the Pa scales (P = 0.04), Pd (P = 0.04), and Sc (P = 0.02) scales.

Tables 3 and 4 show number of patients having elevated scores on Mf, Pa, Sc, Pd, and Ma scales. It was seen that more number of GID patients had these scales elevated compared to control group.

Table 3

Number of patients having high scores in each group

Scale	GID patients (n=56), n (%)	Control (n=54), n (%)
Mf	53 (94.6)	1 (1.8)
Pa	22 (39.2)	1 (1.8)
Sc	21 (37.5)	2 (3.7)
Pd	17 (30.3)	1 (1.8)
Ma	12 (21.4)	0

Mf – Masculinity feminity; Pa – Paranoia; Sc – Schizophrenia; Pd – Psychopathic deviate; Ma – Hypomania; GID – Gender identity disorder

Table 4

Number of patients as per the gender in gender identity disorder group

Scale	Male-to-female transsexuals (n=36), n (%)	Female-to-male transsexuals (n=20), n (%)
Mf	34 (94.4)	19 (95)
Pa	16 (44.4)	6 (30)
Sc	16 (44.4)	5 (25)
Pd	12 (33.3)	5 (25)
Ma	8 (22.2)	4 (20)

Mf – Masculinity feminity; Pa – Paranoia; Sc – Schizophrenia; Pd – Psychopathic deviate; Ma – Hypomania

DISCUSSION

It was expected that in GID group, probably only the Mf scale should be elevated, as it has been shown to be indicative of their condition. In our study, we found that other scales were also elevated in a significant percentage of patients. 39% of them had Pa scale elevated and 37.5% had Sc scale elevated. These findings suggest that patients may have had features suggestive of a psychotic disorder. However, this was untrue as on clinical history and mental status examination, they did not have any symptoms suggestive of the same. When a content analysis of the scales was done, it was found that they had the doubts which were reality based.

Several studies have revealed that the prevalence of psychiatric comorbidities in patients with GID ranges from 15% to 60%. They are likely to suffer from depression, anxiety disorder, specific phobia, and adjustment disorder.[2910]

It is important to note that many patients with GID may show a high score in at least one MMPI subscale other than the Mf scale.[11] Patients with GID are often ridiculed, bear stigma, and face rejection within close family circles. They lose confidence as to who they could confide in and trust or disclose their problems. Even clinicians other than psychiatrists at times may not be sensitive to their needs.[12] This leads to a feeling of distrust and cautiousness when speaking to medical professionals and may lead to a false elevation of Pa and Sc scores, though this elevation is in no way linked to an underlying psychotic process. Most of the profiles assessed in the study were valid and indicated that the patients were truthful in answering, as they were genuinely in distress and sought help for their problems.

CONCLUSION

Our study points out that MMPI scoring of GID patients should be analyzed with extra caution as other scales apart from Mf can be elevated, particularly Pa and Sc which can be reality based. They should not be mistakenly diagnosed as having a psychotic profile which may impair further treatment for them. Probable longitudinal testing in these individuals during different phases of the disorder (before and after surgery, precontemplation, and postcontemplation phases) would probably have added greater yield to psychological assessment rather than a cross-sectional model followed by us. Nevertheless, data on patients with GID in India are sparse, and the MMPI findings in our study are in keeping with a study on larger samples done in specialized centers worldwide. Further studies in larger samples and diverse settings are warranted to corroborate our findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.