1. Background
Gender dysphoria (GD) involves a mismatch between an individual’s experienced gender and their assigned gender at birth (1). Global prevalence data are limited, with incidence rates varying across countries due to cultural factors that influence the presentation and distress associated with GD (2). Studies estimate the prevalence of male-to-female (MTF) transsexuals to range from 1:11,900 to 1:45,000, and female-to-male (FTM) transsexuals from 1:30,400 to 1:200,000 (3, 4). Diagnoses of GD in individuals assigned male and female at birth have increased over the past decade, altering the sex ratio (5, 6). In 1987, Iran legalized sex reassignment surgery (SRS) for individuals with GD, requiring permits from the Forensic Medicine Organization (FMO) (7). Iran was the first country in the Middle East and the second worldwide, after Thailand, to perform SRS (8). However, little is known about the annual number of individuals seeking or receiving this treatment.
2. Objectives
This study assessed the prevalence and demographic characteristics of GD among individuals referred to the FMO in Mazandaran, Iran, from 2016 to 2021.
3. Methods
This study employed a descriptive research design. The Mann-Whitney U test was utilized to compare two groups after assessing the normality of the data using the Kolmogorov-Smirnov test. Chi-square tests were applied to compare qualitative variables, including sex, marital status, residence, education, smoking/drug use, cross-dressing/hormone therapy, and psychiatric disorders, based on medical records. The present study was approved by the Ethics Committee of Mazandaran University of Medical Sciences under the code IR.MAZUMS.REC.1402.517.
4. Results
The results indicated that the prevalence of GD was 123 per 100,000 among individuals referred to the FMO in Mazandaran during 2016 - 2022. During this period, 71 individuals with GD were referred to the FMO in Mazandaran province. Of these, 27 (38%) were MTF and 44 (62%) were FTM, representing a significant difference (χ2 = 4.07, P = 0.05). The average age was 26.9 ± 5.91 years. One individual (1.4%) was married, 65 (91.5%) were single, and five (7%) were divorced. Twenty-one (28.2%) were undergoing hormone therapy before referral to forensic medicine. Fifty-five participants (77.5%) wore clothing of the opposite sex in public places. Regarding residence, 46 individuals with GD (64.8%) lived in urban areas, while 25 (35.2%) resided in rural areas. Educational attainment was distributed as follows: Primary education (10 individuals, 14.1%), high school education (33 individuals, 46.5%), and university education (28 individuals, 39.4%). Table 1 shows the demographic characteristics of individuals with GD referring to FMO in Mazandaran province by year.
| Year | Average Age | Biological Sex | Marital Status | Birth Order | Residence | ||||
|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Single | Married | Divorced | City | Village | |||
| 2016 | 35.45 | 1 | 10 | 10 | 0 | 1 | 2.82 | 6 | 5 |
| 2017 | 28.36 | 5 | 6 | 10 | 0 | 1 | 1.82 | 10 | 1 |
| 2018 | 29.11 | 4 | 5 | 8 | 0 | 1 | 2.56 | 4 | 5 |
| 2019 | 26.83 | 2 | 4 | 6 | 0 | 0 | 2.33 | 5 | 1 |
| 2020 | 24.93 | 9 | 6 | 14 | 1 | 0 | 1.93 | 11 | 4 |
| 2021 | 26.90 | 1 | 9 | 9 | 0 | 1 | 2.20 | 7 | 3 |
| 2022 | 21.89 | 5 | 4 | 8 | 0 | 1 | 1.89 | 3 | 6 |
Demographic Characteristics of Individuals with Gender Dysphoria Referring to Forensic Medicine Organization in Mazandaran Province, Iran by Year
In Table 2, the frequency of people with GD referring to FMO by biological gender and their comparison is presented.
| Variables and Subscales | FTM | MTF | Chi-square | Degree of Freedom | P-Value |
|---|---|---|---|---|---|
| Residence | 6.211 | 1 | 0.013 | ||
| City | 28 | 18 | |||
| Village | 16 | 9 | |||
| Education | 12.366 | 2 | 0.002 | ||
| Primary | 4 | 6 | |||
| Secondary | 17 | 16 | |||
| University | 23 | 5 | |||
| Marital status | 108.620 | 2 | 0.001 | ||
| Single | 38 | 27 | |||
| Married | 1 | 0 | |||
| Divorced | 5 | 0 | |||
| Being employed | 41 | 11 | 1.704 | 1 | 0.192 |
| Smoker | 4 | 9 | 28.521 | 1 | 0.001 |
| Substance user | 3 | 5 | 42.606 | 1 | 0.001 |
| Hormone therapy | 9 | 11 | 1.535 | 1 | 0.700 |
| Wearing cloths of the other sex | 37 | 18 | 21.423 | 1 | 0.001 |
| History of psychiatric disorder | 36 | 24 | 3.17 | 1 | 0.52 |
Frequency of People with Gender Dysphoria Referring to Forensic Medicine Organization in Mazandaran Province, Iran by Biological Sex
5. Discussion
According to a nationwide study assessing the prevalence of GD in Iran between 2012 and 2017, the prevalence was estimated at 0.0000146, with a MTF to FTM ratio of 0.5 (9). This MTF/FTM ratio is similar to the findings of our study. However, the prevalence of GD in our study was higher, possibly due to increased public awareness and reduced social stigma, leading more individuals with GD to seek SRS. Other studies have also reported an increase in the number of individuals with GD seeking medical assistance in Iran and other countries (10, 11).
In the present study, the average age of individuals with GD was 26.9 ± 5.91 years, consistent with other research findings (9, 11). Notably, individuals seeking SRS were younger in 2022 (21.89 years) compared to 2016 (35.45 years). This trend may reflect a shift in Iranian society from traditional to modern values, resulting in greater acceptance of GD and prompting younger individuals to seek help earlier.
It was observed that FTM individuals were statistically significantly more likely than MTF individuals to cross-dress before obtaining permission from the FMO. This may be attributed to Iranian cultural norms, where men and women have distinct clothing styles. It is generally more socially acceptable for a biologically female individual to wear boys' clothing, whereas wearing women's clothing is often taboo for MTF individuals due to societal and familial expectations.
The study also revealed that most individuals with GD had a co-occurring psychiatric disorder, aligning with other studies conducted in Iran. Hedjazi SA et al. (2021) reported a prevalence of co-occurring psychiatric disorders of 32.7% among individuals with GD referred to the FMO in Khorasan Razavi province, Iran (11). This underscores the need for improved mental health services and treatment of psychiatric disorders within this population.
5.1. Limitations
The use of forensic records limited the data available for this study, as key variables such as sexual orientation and family history were not included.
