Endocrine Abstracts (2018) 57 013 | DOI: 10.1530/endoabs.57.013

No correlation between serum testosterone levels and aggression or anger intensity in transgender people: Results from five European Centres

J Defreyne1, J Arcelus2,3, W Bouman2, N Brewin2, E Elaut4, B Kreukels5,6, G Heylens4, M Den Heijer5,6 & G T’Sjoen1,4


1Department of Endocrinology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; 2The Nottingham Centre for Transgender Health, Nottingham, UK; 3Institute of Mental Health, The University of Nottingham, Jubilee Campus, Nottingham, UK; 4Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; 5Department of Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; 6Department of Endocrinology and Center of Expertise on Gender Dysphoria, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.


Aim: Anger is a state of emotions ranging from irritation to intense rage. Aggression is the externalization of anger through destructive/punitive behaviour. The World Professional Association for Transgender Health (WPATH) Standards of Care, Edition 7 (SOC7) guidelines warn about aggression in transgender men (TM) on testosterone treatment. We aimed to assess whether aggression and anger intensity increase in TM and decrease in transgender women (TW) after initiation of gender affirming hormone therapy and to identify predictors for anger intensity in transgender people, including levels of sex steroids as well as psychological measurements.

Method: This work is a collaboration between the Nottingham Centre for Transgender Health, who assessed aggression, and the European Network for the Investigation of Gender Incongruence (ENIGI), who assessed anger intensity. Prospective changes in aggression were measured at baseline and after one year of gender affirming hormones in 155 transgender persons (64 TM, 91 TW), using the Inventory of Interpersonal Problems (IIP-32) factor ‘too aggressive’. Anger intensity was prospectively assessed in 898 participants (440 TM, 468 TW) by the STAXI-2 (State-Trait Anger Expression Inventory-2) State Anger (S-Anger) questionnaire during a three-year follow-up period, starting at the initiation of hormone treatment (testosterone in TM, oestrogens plus anti-androgens in TW). At baseline, psychological questionnaires were administered. Data were analysed cross-sectionally and prospectively.

Results: No prospective changes were reported in ‘too aggressive’ scores (after one year of hormone therapy) and S-Anger scores (over 3, 12 and 36 months of hormone therapy) in TM and TW. ‘Too aggressive’ scores were positively correlated to increasing anxiety scores in the entire study population and with lower support from friends in TW. At three, twelve and thirty-six months of gender affirming hormone therapy, anger intensity was not correlated to serum testosterone levels, although there was a correlation with various psychological measures after three and twelve months. TM experiencing menstrual spotting after three months had higher S-Anger scores compared to those without (median 26.5 [18.0 – 29.8] versus 15.0 [15.0 – 17.0], P=0.020). Changes in STAXI-2 S-Anger scores were not correlated to changes in serum testosterone levels after three, twelve and thirty-six months in TM or TW.

Conclusion: Aggression and anger intensity are associated with psychological and/or psychiatric vulnerability or the persistence of menstruation in TM, but not with exogenous testosterone therapy in TM or serum testosterone levels in both TM and TW.

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