Issues in Diagnosis and Treatment of Transsexualism
Laura Giat Roberto, Psy.D.1
NOTE: tables have been removed from this document they were so scrambled
That they were unreadable.
Transsexualism involves incongruity between anatomy and gender identity in
biological normal persons. The literature in this area indicates controversy
in diagnosis and treatment. Current guidelines for assessment and treatment
selection are critically reviewed. Outcome data suggest that sex reassignment
surgery is variably effective and potentially deleterious. Child and adult
interventions may be more viable than previously assumed. Recommendations for
research include systematic follow-up, longitudinal studies of gender-deviant
children, and studies of psychopathology. Until rigorous outcome data are
available, return to a conservative position on sex reassignment, using highly
exclusive diagnostic guidelines and restrictive selection criteria, is
advocated.
KEY WORDS: transsexualism; sex reassignment surgery; gender identity
disorders.
1Department of Psychiatry and Behavioral Sciences. Eastern Virginia
Medical School, Norfolk, Virginia 23501.
INTRODUCTION
Transsexualism is a condition in which an "anatomy-identity discontinuity"
is experienced (Gagnon, 1977). It is the belief, in a biologically normal
person, that one belongs to the opposite sex, accompanied by the desire to be
and function as an opposite-sexed person (Benjamin, 1966; Stoller, 1968). The
term was first used by Cauldwell in 1949, and is sometimes restricted to only
those persons who have requested and undergone sex reassignment surgery
(Bentler, 1976; Meyer, 1974a).
This paper addresses current issues in the diagnosis and treatment of
transsexualism. While this disorder is still poorly understood, controversies
in management of transsexual patients create the need for a sound conceptual
model. Two positions are identifiable regarding the advisability of surgical
sex reassignment. One position holds that increased willingness to offer
aggressive, radical surgical and hormonal interventions to individuals with
desire for reassignment is unwarranted, due to lack of data regarding
psychopathology (Kubie and Mackie, 1968; Lothstein, 1977a; Meyer, 1974b;
Siomopoulos, 1974). The other position criticizes the practice of labeling
transsexual dysphoria as "quasidelusional," "paranoid" or "suicidal" (Baker,
1969; Finney et al., 1974), and suggests that refusal to grant surgery to
highly motivated and desperate patients is overdetermined (Green, 1967b; Green
et al., 1966b). Preliminary outcome data have intensified the controversy:
the American Medical Association's Commission on Human Sexuality (American
Medical Association, 1972) suggested that surgery may be the treatment of
choice. However, unsatisfactory post-operative outcomes have been reported
(Money and Wolff, 1973; Van Putten and Fawzy, 1976).
In this paper, it is proposed that returning to an extremely conservative
use of sex reassignment surgery is imperative because of the absence of valid
defining characteristics, assessment devices, treatment selection, and
outcome. Although sex reassignment can offer short-term solutions to
immediate management problems with transsexuals, existing outcome data show
little efficacy and even deleterious effects in many patients (Meyer and
Reter, 1979; Stoller, 1973). There is a very small group of patients with a
severe, chronically transposed gender identity and a number of other
distinguishing features (Knorr et al., 1968; Randell, 1971). However, more
rigorous use of existing assessment procedures is necessary to improve
selection criteria. Estimates of prevalence and problems in the diagnostic
validity of transsexualism as a syndrome will be presented. Because of the
necessity for delivering treatment despite the lack of reliable and valid
diagnostic and treatment criteria, existing methods of diagnosis will be
critically reviewed along with suggestions for utilization. Specific
treatment modalities, which may be more viable than was previously assumed,
will be described in terms of goals, procedures, and outcome data. Finally,
suggestions for further research are offered.
Currently, the clinical definition of adult transsexualism is based on a
composite set of characteristics. These include belief that one is a member
of the opposite sex (Fisk, 1974), dressing and appearing in the opposite-
gender role (Fisk, 1974), perceiving oneself as heterosexual although sexual
partners are anatomically identical (Bentler, 1976; Fisk, 1974; Meyer, 1974a),
repugnance for one's own genitals (Pauly, 1969) and the wish to transform them
(Gagnon, 1977; Meyer, 1974a), history of cross-gender activities (Gagnon,
1977; Stoller, 1968, 1969), and persistent desire for sex conversion surgery
(Meyer, 1974a).
Table I. REMOVED
Observation of elementary school aged children (typically boys) using a
number of measurement techniques has suggested some possible antecedents for
adult transsexualism (see Table I). However, longitudinal follow-up studies
of gender-deviant children have not clarified which characteristics antedate
transsexualism as opposed to conflicted homosexuality, transvestism, or no
psychological condition. Children are usually brought to professional
attention between 8 and 10 years of age (Green, 1974, 1978), although these
age trends are currently dropping as treatment facilities are more available.
Individuals most frequently seek assistance for transsexualism in late
adolescence or early adulthood.
Table II. REMOVED
PREVALENCE
Actual incidence and prevalence of transsexualism is presently unknown.
Surveys performed to date in the United States and Europe have yielded
estimates for each sex and for sex ratios (see Table II). Researchers
consider their data on treated prevalence to be underestimates (Hoenig and
Kenna, 1973; Mehl, 1974). The ratio of males to females approximated 3:1 in
the early 1970s, but gender identity clinics in locations as disparate as
Sweden and Oregon now report ratios approximating 1:1 (Pauly, 1974). Older
literature and cross-cultural field studies suggest that cases were
predominantly male (e.g., Green, 1966). However, differentiation of
transsexualism from transvestism (simple cross-dressing) was not reliable
until the late 1800s. Allowances must therefore be made in interpretation of
historical case material.
Survey methods utilized thus far have several methodological problems:
1. It is assumed that only intolerably stressed transsexuals consult
mental health professionals, yielding a very low estimate of true prevalence.
2. Many of the surveys have used mailed questionnaires with an attenuated
return rate (76%, according to Walinder, 1967).
3. Diagnostic criteria are unclear and poorly differentiated, yielding a
mixed diagnostic group.
4. Surveys often utilize unstructured psychiatric interviews without a
"blind" interviewer, introducing research bias (e.g., Hoenig and Kenna, 1973).
SEARCH FOR A SYNDROME
Research on transsexualism is still at the stage of clinical description.
Well-controlled studies of pathognomonic char-acteristics using proper
diagnostic validation procedures are lacking. In addition, classification
systems based on these criteria have not been studied to determine overlap of
measurement and differential utility. Studies that do attempt to test
diagnostic criteria using systematic measures (such as sexual history and
satisfaction with surgical outcome) include the work of Bentler (1976) and
Meyer (1974a).
Gender identity disorders are seen essentially as disturbances in the
fundamental sense of belonging to one's own biological sex. Transsexualism,
the most extreme form, is accompanied by gender dysphoria and the active
desire to change one's anatomical sex to match the psychological gender.
Changes in core (biological) gender identity (Stoller, 1968), psychological
gender identity (Money and Ehrhardt, 1972), gender role, and gender dysphoria
(Fisk, 1974; Bentler, 1976) are all involved. According to Meyer (1974a),
transsexuals show four common characteristics:
1. Inappropriateness or incapacity in the anatomically determined gender
role
2. The belief that improvement will result from role reversal
3. Choice of sexual partners of the same anatomic sex, and inhibition of
heterosexual interest
4. Desire for sex reassignment surgery
These attributes readily distinguish gender identity disorders from
atypical sexual orientations, from sexual dysfunctions, and from variant
erotic preferences. For example, variant erotic preferences such as
sadism/masochism do not necessarily include incapacity in assigned gender
role, desire for role reversal, choice of same-sex partner, or desire for
surgery (Benjamin, 1967; Buhrich and McConaghy, 1977a, 1977b; Prince, 1974).
Any of these other three disorders may coexist with a gender identity
disorder, but they involve separable patterns of psychosexual arousal and
interpersonal behavior.
Because the attributes common to all transsexuals differentiate them as a
group from other sexual disorders, it is tempting to assume that there is a
discrete, unitary syndrome. In fact, there is considerable heterogeneity in
this population (Bentler, 1976; Fisk, 1974; Gandy, 1974; Meyer, 1974a, 1974b;
Pearson, 1974). Patients can be differentiated into approximately four groups
(see Table III) on the basis of sexual behavior and reported partner choice.
These behavior patterns have been observed predominantly in male sex
reassignment applicants and may not be generalizable to females. Further,
certain identified groups have been extremely small (e.g., Meyer's "young
fetishistic transvestites," N = 3, 1974a), which also creates questionable
generalizability.
Group 1 ("homosexual") shows a history of late-onset cross-dressing without
arousal. It includes homosexual males who claim anxiety, guilt, and
stereotyped "feminine" mannerisms. Partner choice has always been for the
same anatomic sex. Group 2 ("heterosexual transvestitic") reports a history
of cross-dressing that may or may not have led to arousal. This group has
shown intermittent or predominantly opposite-sex partner choice. Meyer
(1974a) reported what may be an age trend in the fetishistic arousal, but used
a cross-sectional sample. Other clinicians have also noted a dropping off of
arousal with age in individual patients.
Table III. REMOVED
Groups 3 and 4 have been viewed as two different populations, "asexual" (or
"classical" transsexualism) and "schizoid," but both show minor or absent
responsivity to any sexual partner. Individuals are described as emotionally
withdrawn and impoverished in interpersonal relationships, although persons
labeled as asexual are more likely to report a history of cross-gender
striving than those labeled schizoid.
Group 5 ("psychotic"), is diagnosed on the basis of overt thought disorder
and presence of somatic delusions. It has accounted for as many as 25% of sex
reassignment requests (Fisk, 1974; Knorr et al., 1968). Persons diagnosed as
schizophrenic express severe gender identity confusion, and certain sex
reassignment applicants have shown a degree of somatic preoccupation that
reflects impaired reality testing (Knorr et al., 1968; Kubie and Mackie, 1968;
Siomopoulos, 1974).
These transsexual groups overlap to some extent as presently defined.
Bentler (1976), in a comparative study of 42 postoperative male transsexuals,
did empirically separate out three primary groups: "homosexual," "asexual,"
and "heterosexual." These groups yielded data on self-report questionnaire
items that differentiated them (in post hoc between-group comparison) on
socioeconomic status, average age, education, reasons for surgery,
preoperative and postoperative sexual activity, and satisfaction. However,
while several groups show clearly differentiable characteristics (e.g.,
schizophrenia vs. "homosexual" transsexualism), the four nonpsychotic groups
(1, 2, 3, and 4) are too idealized to fit most patients (Meyer, 1974a).
Gender identity and gender role should be best conceptualized as a cognitive
and behavioral continuum in which discrete conditions cannot be separated off
with confidence. Degree of cross-gender identity appears to vary clinically
between individuals (Stoller, 1973), supporting the notion that strength of
primary gender identification may be a clinically significant variable.
A number of clinicians have noted that patients with cross-gender identity
show accompanying psychopathology. This raises critical questions regarding
transsexualism as a discrete category of psychopathology at all, as opposed to
a manifestation of an underlying condition such as schizophrenia or paranoid
psychosis (Kubie and Mackie, 1968; Siomopoulos, 1974). Few studies have
utilized standardized psychometric instruments to investigate psychopathology,
so there is little convergence of opinion (Doorbar, 1969; Finney et al., 1974;
Paitich, 1974; Pearson, 1974).
Two diagnoses given consistently in many sex reassignment applicants, based
on MMPI criteria and individual and family interviews, are hysterical
personality and paranoid personality (Finney et al., 1974; Pearson, 1974;
Stoller, 1968). Finney et al., (1974) found hysterical characteristics to be
major or secondary in 67% of cases assessed. Less frequently, sociopathic
personality and inadequate or schizoid personality have been diagnosed (Fisk,
1974; Meyer, 1974a; Paitich, 1974; Pearson, 1974). Depression has been
reported in several transsexual subgroups (Doorbar, 1969; Finney et al., 1974;
Paitich, 1974), but the extent to which the observed depressions were
situationally reactive was not assessed. Depression, self-deprecation,
"paranoid" behavior, and interpersonal exploitativeness could be the result of
social stigma and professional skepticism (Baker, 1969).
DIAGNOSTIC INSTRUMENTS AND CLASSIFICATION SYSTEMS
Because of the lack of inclusion and exclusion criteria noted above, many
assessment instruments are not adequately reliable and valid for differential
diagnosis and treatment disposition. For example, transsexualism is often
labeled as transvestism because of failure to distinguish between cross-
dressing which is fetishistic (causes sexual arousal) and that which does not
(Baker, 1969). Poor standardization and validation procedures have further
detracted from the utility of these instruments.
Diagnostic Instruments
The primary assessment instrument is the unstructured interview with
patient self-report. A notable exception is the structured interview schedule
used by Money and Primrose (1969), which covers four major areas: sexual
history, psychosocial history, medical/developmental history, and
fantasy/associational content. Significant others are asked to corroborate
historical data. Tests of intelligence, visual-motor integration, and gender
role are included, as well as neurological, physical, and endocrinological
assessment. This interview schedule is more thorough and better documented
than those commonly reported.
Self-reported symptoms and treatment requests are often weighted too
heavily (Friedman et al., 1976; Knorr et al., 1968; Kubie and Mackie, 1968;
Meyer, 1974a; Stoller, 1973). Because sex reassignment applicants believe
that only genital alteration will resolve their gender dysphoria, they are
highly motivated to obtain surgery. Memory is often skewed, or responses
distorted, to report only those perceptions and feelings that clearly indicate
early-onset cross-gender identity (Knorr et al., 1968). The self-labeled
transsexual often has had childhood intervention, and tends to assume the
evaluation will be used to convince him/her that the adopted gender identity
and role are inappropriate and should be reversed (Fisk, 1974; Knorr et al.,
1968). Because of pressure from the professional's gate keeping function and
from the patient's persistent desire for surgical sex reassignment, this self-
report data resembles the idealized transsexual description reviewed earlier.
Independent measurement of critical social, sexual, and psychological
variables (Edgerton et al., 1970; Mehl, 1974; Money and Ehrhardt, 1972) is
often neglected.
Auxiliary assessment techniques will enhance the validity of interview data
if used systematically, including the mental status examination, personality
instruments, and behavioral assessment. Kubie and Mackie (1968), in an
excellent review of diagnostic and treatment issues, have called for
construction of specific tests of gender identity and gender role. Behavioral
observation in a laboratory setting (Barlow et al., 1973; Rekers et al.,
1976), card sort (Barlow et al., 1973), projective tests (Doorbar, 1969), and
masculinity/femininity scales such as MMPI Subscale 5 (Paitich, 1974) have all
been applied and could be combined to yield an algorithm with predictive
value.
A rich source of behavioral observation is the "real-life test", originally
intended as the initial phase of sex reassignment treatment. During the 1-3
year test, patients live and dress in the opposite-gender role, receive
hormonal therapy, and conduct their social and vocational lives accordingly.
Observations during this period indicate level of tolerance for emotional
distress, degree of social skill in the adopted role, and motivation to
undergo permanent sexual reorientation. The test should serve as a
confirmation phase of the cross-gender diagnosis (Money and Walker, 1977).
For example, Walker (1976) observed that nonfetishistic male transvestites who
experience strong feminine identifications found consistent cross-gender
behavior intolerable and returned to episodic role-switching.
Since a clearcut set of inclusion and exclusion criteria for transsexualism
is not available, a "best-fit" decision must be made based on interpersonal
and sexual history. Critical questions include the following (Knorr et al.,
1968):
1. Rigidity of cross-gender identity
2. Chronicity of cross-gender identity
3. Primacy of cross-gender identity (rule out psychosis)
4. Ability of patient to acceptably enact (socially, vocationally and
sexually) the cross-gender role
Individuals who fulfill these criteria must further be distinguished from
those who wish to appear transsexual. The desire to alter gender role and
body outline can represent a maladaptive solution to other, more acute types
of emotional distress (Friedman et al., 1976; Kubie and Mackie, 1968). For
example, some homosexual males who are unsuccessful in their social
communities come to believe that a more feminine body would increase
popularity and appear revolted by their genitalia. However, there is a
history of genital pleasurability in these cases. In order to avoid false
positive judgments, potentially distorted self-report data must be
supplemented with multiple reporters and multiple assessment occasions
(Walker, 1976).
Classification Systems
Transsexuals are classified either by using a nosology specific for gender
identity (e.g., Fisk, 1974) or by using the standard psychiatric nomenclature
(e.g., DSM III; American Psychiatric Association, 1978). The previous
discussion of subgroups in transsexualism suggests that as far as possible
this population should be distinguished from homosexuality, transvestism, and
schizophrenia with gender identity confusion and dysphoria (Benjamin, 1967;
Buhrich and McConaghy, 1977b; Freund, 1974; LaTorre, 1976; Ovesey and Person,
1973; Roback et al., 1977). Thus, a rigorous diagnostic procedure should
first distinguish between two major classes of psychological disorder: (l)
psychosis, and (2) personality disorder-psychosexual subtype (Benjamin, 1954;
Calnen, 1975; Kubie and Mackie, 1968; Siomopoulos, 1974). To date, no single
classification system has specified criteria for classing symptoms in this
manner. Two major systems were developed for use (see Table IV): DSM III
(American Psychiatric Association, 1978) and the Stanford University Gender
Reorientation Program system (Fisk, 1974).
Table IV. REMOVED
DSM II (American Psychiatric Association, 1968) offered no subcategory of
psychosexual disorders specific for this clinical group. Psychosexual
disorders in DSM III do include a subset of gender identity disorders with
highly specified defining criteria. However, transsexualism is divided into
three subgroups designated by Bentler (1976). While the Stanford University
system (Fisk, 1974) also offers a set of subgroups, it contains several that
have not been reported elsewhere ("inadequate schizoid" personality;
"sociopathic" personality) and omits the "asexual" pattern (Bentler, 1976;
Meyer, 1974a). Since the "schizoid" and "asexual" patterns may be quite
similar in terms of interpersonal history, sexual functioning, motivations for
surgery, and postsurgical outcome, these two subgroups require further
comparison. The Stanford system, a two-step procedure, identifies first the
presence of severe gender dysphoria and second the subgroup of gender
dysphoria. The emphasis on dysphoria as the primary diagnosis represents a
broader class of inclusion criteria (Fisk, 1974) when compared with DSM III.
Given our current lack of knowledge regarding the history, nature, and course
of transsexualism, this broad inclusion criterion may yield an overly high
rate of false positive diagnoses.
The assessment procedures available for diagnosis must be more rigorously
applied. Although we can only speak of a "best-fit" method of diagnosis at
present, it is possible that gender dysphoric patients can be validly
differentiated into subgroups on the basis of sexual history, chronological
appearance of symptoms, extent of cross-gender identification, chronicity, and
other sexual and interpersonal variables. The outcome of surgical or
psychotherapeutic intervention may differ radically for these different
individuals (Bentler, 1976). However, more between group comparisons must be
conducted, on a wide range of criterion variables, to clarify the actual
uniqueness of these subgroups and their existence as a diagnostic entity.
TREATMENT STRATEGIES AND COMPLICATIONS
There is considerable disagreement regarding the treatment of choice for
transsexualism. Since specific treatment methods are usually not presented in
the literature, procedures must be inferred from case descriptions and
theoretical statements. Specific treatment outcomes for the three transsexual
subgroups have not been researched, with the exception of Bentler's (1976)
descriptive study. Further follow-up studies are lacking for most treated
transsexuals (Stoller, 1973), so conclusions regarding therapeutic
effectiveness are frequently based on speculation. Finally, authors are more
likely to publish successful than unsuccessful outcomes (Pauly, 1965;
Walinder, 1967).
Researchers who believe that transsexualism represents a crystallized
gender identity transposition, fixed during a "sensitive period" in childhood,
hold little hope for a psychological means to reverse it (Baker, 1969;
Benjamin, 1967; Knorr et al., 1968; Money and Gaskin, 1970-1971; Pauly, 1968;
Stoller, 1968; Walker, 1976). Those who view transsexualism as a delusional
belief reflecting emotional conflict feel that transsexuals may be accessible
to psychotherapy (Kubie and Mackie, 1968; Lothstein, 1977a 1977b; Meyer,
1974a; Siomopoulos, 1974). It appears true that reversal cross-gender
identity has not been demonstrated in many cases of adult transsexualism
(Baker, 1969; Pauly, 1968; Money and Walker, 1977; Walker, 1976; Weitz, 1977),
although there have been exceptions. An experimental behavioral program
applied in three cases was successful in changing gender identity (Barlow et
al., 1973, 1979). A fourth documented case showed evidence of cure by faith
healing (Barlow et al., 1977). Most practitioners agree that "the general
rule that applies to treatment of the transsexual is that no matter what one
does - including nothing - it will be wrong" (Stoller, 1968). Many of these
individuals show extreme resistance to psychological intervention, so that
effective psychotherapy aimed at gender identity reversal is not considered
likely. However, this fact has often precluded even consideration of
nonsurgical interventions. Under these conditions, clinicians may view
patients as "untreatable" rather than "resistant" persons with long-term
patterns of disorder.
A second treatment controversy involves management of the strong resistance
manifested by transsexual adults toward psychotherapy. They wish to be the
opposite sex - to function in it sexually, to be entitled to the legal and
social status of that sex, and to eliminate the dysphoria they feel in their
anatomical state (Benjamin, 1967). Because nothing less than sex reassignment
would cause this dramatic change, gender dysphoric patients are extremely
averse to focusing on their dysphoria as a problem (Benjamin, 1967; Knorr et
al., 1968; Lothstein, 1977a; Mensh, 1972; Pauly, 1968 Walker, 1976; Weitz,
1977). Viewing psychotherapy as an obstacle to or refusal of surgery, their
persistently confused, hostile, urgent, and mistrustful communications are
demoralizing to professionals (Baker, 1969; Green, 1967b; Green et al., 1966b;
Lothstein, 1977a, 1977b). Establishing a working alliance is difficult if the
therapist is unwilling to tolerate this urgency, or if s/he insists on a
nonsurgical intervention from the outset. However, some investigators report
that an empathic approach, presenting psychotherapy as an opportunity for
exploration prior to considering irreversible surgery, often increases
motivation (Meyer, 1974a).
The major therapeutic approaches include intensive psychoanalytic
psychotherapy, supportive psychotherapy, group psychotherapy, behaviorally
oriented psychotherapy, and gender reorientation with surgical sex
reassignment. These apply to adults and late adolescents only. Early
childhood interventions, which appear very viable (Green, 1978), constitute a
separate class of procedures.
Intensive Psychoanalytic Psychotherapy
The goal of treatment is to stabilize the transsexual in a nonoperated
state which will allow him/her to adapt to social and vocational living
without surgery, or to reverse the cross-gender identity if it is unstable
(Green et al., 1966a; Stoller, 1973; Stoller and Rosen, 1959). The assumption
is that transsexual ideation is a rigid defense against anxiety-producing
gender role incompetence rather than a developmental disturbance in core
gender identity (Kirkpatrick and Friedmann, 1976; Knorr et al., 1968). The
principle is to reconcile psychological gender with anatomical sex or to make
it possible to tolerate the anatomical sex (Benjamin, 1967). Technique is not
specific to transsexualism. Interpretation is used to clarify the function of
the cross-gender identity as a defense against unacceptable impulses and self-
perceptions. Recent psychoanalytic publications regarding treatment of severe
personality disorders suggest that a critical factor in establishing a
successful working alliance is recognition and use of therapist responses
(Lothstein, 1977b). One exploratory study (Lothstein, 1977a) identified
specific therapy "stages" in which patient responses (e.g., suspicion and
devaluation) appeared to covary with therapist responses (e.g., confusion and
rage). Most researchers view analytically oriented psychotherapy as
ineffective for altering cross-gender identity (Baker, 1969; Knorr et al.,
1968; Stoller, 1968; Weitz, 1977), although other authors report variable
outcome (Kirkpatrick and Friedmann, 1976; Lothstein, 1977b).
Complications of treatment have been reported. Lothstein (1977a) notes
that suicidality or decompensation of functioning may occur because anxiety
often increases either at termination or with a decision for surgery. Pauly
(1968) states that "transsexual patients have been pushed into psychosis" by
attempts to challenge and reverse the cross-gender identity, but without
presentation of data. Don (cited in Forester and Swiller, 1972) states that,
when challenged in this way, up to 30% of patients developed paranoid ideation
in individual psychotherapy and began to experience cognitive disorganization.
Motivation for psychotherapy and stress tolerance are, however, difficult to
induce while routine sex reassignment surgery is sanctioned by the social and
scientific communities.
Supportive Psychotherapy
The goal of treatment is to help the transsexual cope with alienation,
social rejection, and other feelings concomitant with cross-gender identity,
with the assumption that psychotherapy usually cannot reverse the condition
(Baker, 1969). This approach avoids deliberate initiation either of gender
reorientation or of stabilization, focusing instead on increasing skill level
in interpersonal relationships and toleration of emotional stress. The
assumption made is that necessary social skills did not develop, resulting in
formation of inadequate, withdrawing, alienated personalities (Roth, 1974).
The patient is encouraged to explore social and sexual experiences and affects
surrounding the gender of birth, and motivations for desiring sex change. In
an illustrative study of an extremely effeminate male transsexual, frustration
tolerance and reality testing increased, and hostile behavior and entitlement
decreased. Depression and social anxiety increased, and the patient's gender
identity became less rigidly transposed during therapy (Roth, 1974).
Group Psychotherapy
As in intensive psychoanalytic psychotherapies, the goal of a group
approach is to help the patient adjust his/her gender identity without
irreversible genital surgery. This psychotherapy has not been widely
attempted (Sadoughi et al., 1974). As in supportive approaches, the
assumption made is that historically, as a consequence of social isolation,
heterosocial skills were not learned, and an inadequate or constricted
personality with a same-sex object choice resulted. In the single case report
published (Forester and Swiller, 1972), the authors state that an initial
attempt at individual psychotherapy apparently failed due to fear of male
authority figures. In a group setting the conflict was redefined as anxiety
and failure in male role activities, and a decrease in transsexual symptoms
occurred.
Groups currently offered as part of the transsexual evaluative procedure
(Sadoughi et al., 1974) also proceed around informal exchange in an atmosphere
that encourages discovery of the patient's patterns of adjustment to
psychological stress. Once the group frame of reference is established, some
patients have decided against surgery in this context, opting instead for
psychotherapy.
Behaviorally Oriented Psychotherapy
The goal of this intervention is modification of those gender role
behaviors that lead the patient and observers to label him/her as gender-
inappropriate, and change of those beliefs which s/he attributes back to the
gender of birth. The assumption, as in the group and supportive approaches,
is that transsexual ideation and behavior represents a set of inappropriate
responses learned in the early childhood environment, coupled with failure to
incorporate gender-appropriate behavior from peers due to ensuing social
isolation (Bates and Bentler, 1973; Bentler, 1976; Green, 1967a; Green et al.,
1972b; Mischel, 1970). As these individuals become more and more deviant in
contrast to peers, cognitive self-categorizations and labeling processes lead
to formation of cross-gender identity (Bentler, 1976).
The most successful program to date, utilized in three cases, first
attempted to modify effeminate gender role behavior in male transsexuals, and
then instituted modeling and behavioral rehearsal of gender-appropriate
behavior. Fantasy training was incorporated using shaping, stimulus fading,
and reinforcement for heterosexual fantasies and electrical aversion for
homosexual fantasies. After this five-stage modification, transsexual
attitudes reportedly dropped to near-zero frequency as indicated by card sort
(Barlow et al., 1973, 1979). At follow-ups ranging from 1 1/2 to 6 1/2 years,
treatment gains were maintained. Earlier behavioral techniques, which used
aversive reconditioning alone (Gelder and Marks, 1969; Randell, 1971), were
not successful in eliminating gender dysphoria or transsexual attitudes.
Treatment complications have not been reported in the literature. The
chief disadvantage to this technique at present lies in its intricacy and use
of extensive audiovisual aids, which precludes wide usage outside the
laboratory. Further, the relationship between gender-related statements
endorsed in card sort and gender identity as experienced subjectively and
interpersonally has not been established.
Gender Reorientation with Surgical Sex Reassignment
Surgical sex reassignment involves direct modification of the genitals by
removal of external organs and plastic reconstruction of genitals to give the
appearance of opposite-sex organs (Benjamin, 1967). Reassignment is
incorporated into a five-stage program:
1. Evaluation to determine appropriateness for surgical sex reassignment
2. Exploratory psychotherapy to determine whether the wish for
reassignment is mutable and to correct misconceptions regarding surgery
3. Hormone administration for modification of some secondary sex
characteristics
4. Real-life test (with hormone maintenance)
5. Sex reassignment surgery
Prior to any decision regarding an offer of surgery, attempts are made to
identify gender dysphorics for whom surgery would be contraindicated. These
groups include patients with psychosis, sociopathy, organic brain syndrome or
defective intelligence, severe depression, successful history in marital or
parental roles, successful functioning in heterosexual intercourse, gender
role behavior which is appropriate now or has been in the past, and
transvestitic or homosexual history with reported genital pleasure (Baker and
Stoller, 1968; Knorr et al., 1968; Randell, 1971; Stoller, 1973). Tragic
postoperative outcomes that have been reported appear to have been due to
misdiagnosis or acceptance of patients with severe preoperative emotional
disturbance (Golosow and Weitzman, 1969; Hertz et al., Money and Wolff, 1973;
Stoller, 1973; Van Putten and Fawzy, 1976).
Postsurgical outcome depends on the history of psychological and social
functioning, and a stressful or unsuccessful history suggests a similar range
of problems after surgery, although not necessarily a continuing gender
identity problem (Bentler, 1976; Gagnon, 1977; Knorr et al., 1968; Sturup,
1976). The purpose of exploratory psychotherapy is to confirm the diagnosis
of primary transsexualism, to observe the patient's stress tolerance and
reality testing, and to convey that surgery is not a gender reassignment but
rather a modification of sexual functioning (Benjamin, 1967; Green, 1969;
Prince, 1974; Randell, 1971). Because of isolation from peers, idealized
stereotypes often have evolved regarding living in the new gender identity
(Gagnon, 1977). For example, male transsexuals often imagine that after
surgery they will become sexually appealing, adored, and protected housewives
who can raise children and care for the household. The reality of social
stigma, legal harassment, family withdrawal, relationship failure, and
unemployment is in harsh contradiction with such fantasies (Randell, 1971).
The "real-life test" requires that patients live in the desired sex
vocationally and socially, to prove their ability to function in the
reassigned gender (Wojdowski and Tebor, 1976). It is a probationary period of
at least 1 year used by most university hospitals in the U.S. (Mehl, 1974;
Money and Gaskin, 1970-1971; Money and Walker, 1977; Walker, 1976). The phase
includes oral or intramuscular hormone therapy for suppression of existing
secondary sex characteristics and maintenance of an opposite-sex phenotype.
During this period, a number of incorrectly diagnosed patients have been
revealed as false positives (Walker, 1976). Reported failures in reassignment
often reveal that a real-life test was not employed (Money and Wolff, 1973).
Surgical procedures for altering secondary sex characteristics include
augmentation mammaplasty, shaving of laryngeal cartilage, rhinoplasty,
testicular implants, bilateral mastectomy, depilation, and bone/cartilage
insertion into tubed penile flaps (Edgerton et al., 1970). In males, a four-
part procedure is performed: (l) penectomy; (2) castration; (3) labial
reconstruction; and (4) formation of an artificial vagina by inversion of
penile skin and/or free skin graft (Flowers, 1974). In females, bilateral
mastectomy is performed, although there is no satisfactory technique for
forming a functional penis.
There are many postoperative complications, especially in cases where
surgery has been performed in poorly equipped and trained hospitals outside
the U.S. Hore et al., (1975), in a sample of eight patients who received
vaginoplasty, noted four urethral strictures, four rectovaginal fistulas, two
urethral fistulas, one graft-caused infection, two deep vein thromboses, and
two cases of vaginal stenosis after vaginal molds had fallen out
postoperatively. Five of eight suffered poor postoperative adjustment, three
due to the surgical complications and two due to unrealistic expectations that
they would feel "fully female."
Frequency of surgical complications, problems, and later course of
adjustment are not known due to lack of controlled studies. Existing data
draw on self-reported satisfaction and stability in sexual and social
relationships, ability to maintain employment, police records, psychiatric
contacts, marital status, and mental status (Baker, 1969; Benjamin, 1967;
Bentler, 1976; Edgerton et al., 1970; Friedman et al., 1976; Meyer and Reter,
1979; Money, 1971; Pauly, 1968; Randell, 1971; Sturup, 1976; Van Putten and
Fawzy, 1976). According to these descriptive studies, only a handful of cases
from among the hundreds operated have been failures ending in severe
depression, psychotic decompensation, or suicide. However, a closer look at
studies concluding "generally satisfactory results" reveals significant
problems which are skirted. In one follow-up study (Sturup, 1976), 10 male
transsexual cases were examined by unstructured interview. At outcome, 6 of
10 patients, "asexual" transsexuals, claimed satisfaction, but their case
descriptions reveal significant difficulty in establishing stable
relationships, social withdrawal, depression, and in one case a suicide
attempt. Three of the 10 patients, "promiscuous homosexual" transsexuals,
claimed satisfaction, and after surgery worked as prostitutes. The tenth
patient still lives as a male.
A recent study of operated versus unoperated transsexuals at Johns Hopkins
Hospital improves on earlier research (Meyer and Reter, 1979). Thirty-five
patients who had not yet opted for the real-life test were interviewed and
followed up analogous to wait-list controls. Comparison of reassigned, late-
reassigned, and unoperated patients suggested that surgery did not result in
any statistically significant change in legal, socioeconomic, or marital
status. Both reassigned and unoperated groups improved slightly over the
course of time. This study has, however, been severely criticized by other
investigators (e.g., Fleming et al., 1980). Outcomes reported elsewhere have
been variable: number of patients who are more dysphoric following surgery, 0-
45%; number of patients lost to follow-up, 12-46% number of patients who show
good or excellent social and emotional improvement and satisfaction, 60-100%
(Benjamin, 1967; Edgerton et al., 1970; Friedman et al., 1976; Hore et al.,
1975; Money, 1971; Pauly, 1965, 1968; Randell, 1969, 1971; Sturup, 1976).
Psychological effects of surgery have included psychotic decompensation or
sudden reversal to the gender of birth (Childs, 1977; Golosow an Weitzman,
1969; Hertz et al., 1961; Money and Wolff, 1973; Randell, 1969; Benjamin,
1966; Van Putten and Fawzy, 1976). With some patients and/or families
litigation has followed sex reassignment because of disappointment with
surgical results, even barring postoperative complications (Pauly, 1968).
Preliminary data point to increased postoperative dissatisfactions and
complications in "asexual" and "homosexual" transsexuals (Bentler, 1976;
Meyer, 1974b). In a small group of transsexuals who show early-onset cross-
gender identity, social skill in the opposite gender role, and intact judgment
and cognitive functioning, surgery has appeared to successfully confirm the
internal gender identity (Stoller, 1973). However, it is clear that the lack
of diagnostic precision in current practice is responsible for many
misassignments to surgery.
The evidence for intensive psychoanalytically oriented psychotherapy
suggests rare incidence of improvement. Supportive psychotherapy,
individually or in groups, has not been widely reported in the literature to
date. A proposed group technique (Forester and Swiller, 1972) resulted in one
successfully treated case, although the patient presented with gender-
appropriate mannerisms and physical attributes.
Recent behavior techniques relying on modeling with feedback of appropriate
gender role behaviors, use of verbal praise, shaping of heterosexual fantasies
with stimulus fading, and aversive conditioning for homosexual fantasy
resulted in three successful cases (Barlow et al., 1973, 1979). Such a
treatment program appears quite promising but has remained underutilized,
possibly due to the extensive nature of the laboratory procedures.
Gender reorientation and sex reassignment surgery has presented a radical
intervention which, for patients willing to undergo the multiple phases,
resolves many of the initial complaints. However, severe treatment-related
disorders have resulted (psychotic decompensation, maladaptive interpersonal
behavior, severe depression or paranoid ideation, and suicide). In a small
group, treatment has resulted in a more successful adaptation socially,
vocationally, and sexually in the new gender role. However, the expense,
pain, and psychological trauma clearly suggest that less intrusive techniques,
such as behavioral interventions or trials of intensive psychotherapy for
severe personality disorder, are indicated as an initial effort.
Childhood Interventions
Unlike the case with late adolescents and adults, gender reorientation can
be accomplished for children who show evidence of gender-inappropriate
behavior and cross-gender identity (see Table I). If intervention is begun in
early childhood, it is possible that cross-gender identifications can be
modified before the effects of the developmental "critical period" (ages 3-5)
are immutably consolidated (Baker, 1969; Money et al., 1957; Stoller, 1967,
1968). Because gender identity formation is more malleable in childhood, it
has been proposed that therapeutic intervention be focused on this age group
(Green, 1978; Green and Fuller, 1973). The goal of treatment is to reduce
immediate psychological distress and social ostracism, and thus potentially to
prevent adult sexual or gender identity disturbances (Green, 1974, 1978;
Wolfe, 1979).
Most adult transsexuals report an early cross-gender identity (Benjamin,
1966; Green, 1974; Stoller, 1968). A study of 500 adult transvestites
revealed that half began cross-dressing before puberty (Prince and Bentler,
1972). Homosexual males often report effeminate behavior in grade school
(Zuger, 1966). In three follow-up studies of previously diagnosed effeminate
boys totaling 26 subjects, 14 were judged heterosexual (Green, 1974; Lebovitz,
1972; Zuger, 1966). However, although gender-inappropriate behavior in
childhood may not represent a marker for adult transsexualism, a case can be
made for intervention whether or not it will serve as prevention. There is
evidence that, in boys, cross-gender fantasies and desires for sex change
produce discomfort whether or not the social environment approves, and whether
or not a long-term gender identity problem is involved. Families also become
concerned regarding such children's peer difficulties (Green, 1974,1978;
Rekers et al., 1977).
Major treatment approaches for children involve both individually based
child intervention and group-based parent intervention (Green, 1974, 1978;
Green and Fuller, 1973; Rekers et al., 1976). With the child, psychotherapy
focuses first on sex education. The positive aspects of the child's own
gender are emphasized, and his/her reasons for desiring the role and
activities of the opposite gender are discussed. Stereotypes concerning
activities allowable to each gender are corrected. With boys, a male
therapist is utilized to encourage male identification; few girls are referred
for treatment. If possible, same-sex playmates who are neither stigmatized
nor role stereotyped, are found in the community to strengthen the conflicted
gender identity. A play therapy group is added to further strengthen the
gender identity.
With the parents, intervention follows two tracks: education in behavior
modification to reinforce gender-appropriate behavior and extinguish
inappropriate behavior; and use of a couples group and parent group. In
fatherless households, male relatives or "big brothers" are found (Green,
1967a). In parent groups, mutual adult supportiveness and peer supervision
are used to monitor consistency of child-rearing practices and parental
relationship problems with the child.
Preliminary outcome data indicate that children with evidence of atypical
gender identity do respond to intervention by shifting toward the typical
range of gender role behavior (Green et al., 1972b; Rekers and Lovaas, 1974;
Rekers et al., 1974, 1976; Rekers and Varni, 1977a, 1977b). Parent narratives
and home behavioral ratings prior to and during therapy indicate that change
occurs on a variety of dimensions: less cross-dressing; less "feminine"
mimicry; less opposite-gender role taking; fewer verbalizations of dysphoria;
and closer father-son relationships. However, the relationships between
gender role behavior, internal gender identity, and later sexual object choice
remain unclear (Green and Fuller, 1973; Green, 1978; Wolfe, 1979).
One caveat concerning childhood intervention, however, stems from the fact
that it does appear effective in modifying cross-gender behavior. While
treatment seems indicated because of the children's distress and social
isolation, the methods used involve reinforcement for stereotyped gender role
behaviors. This provides an extremely limited perspective on
masculinity/femininity in our culture and perpetuates a value system based on
gender-specific socialization (Gagnon, 1977; Wolfe, 1979). A second danger is
that, under parent and peer pressure, children may try voluntarily to suppress
"offensive" behaviors rather than internalizing a change in gender
orientation. A further possibility is that behavior modification that
punishes gender-deviant behavior and rewards gender-normative behavior can
also train out desirable traits that are personality, not gender,
characteristics. The better alternative would be intervention that would also
help to modify the gender-stereotyped school and community environments where
stigmatization occurs.
SUMMARY AND RECOMMENDATIONS
Transsexualism has captured historical and current scientific interest
because it is so severe a disorder, resistant to change in adulthood. First
treated with genital reconstruction by Hamburger and colleagues in 1953, in
recent years requests for relief from gender dysphoria have become more common
(Hamburger, 1953; Hamburger et al., 1953). Resulting experimentation with
treatment of transsexuals has led to controversy in theory and practice
between researchers who believe that the condition is accessible to
psychotherapy (Kirkpatrick and Friedmann, 1976; Kubie and Mackie, 1968;
Lothstein, 1977a, 1977b) and those who believe that only gender reassignment
is possible (Baker, 1969; Benjamin, 1966, 1967; Money and Gaskin, 1970-1971;
Pauly, 1968; Walker, 1976).
Discovery in the last decade of transsexual subgroups (Bentler, 1976;
Meyer, 1974a) has led to speculation that transsexualism is not a homogeneous
syndrome but reflects a condition that may result from multiple psychosocial
and sexual histories, motivations, self-concepts, and stress-coping strategies
(Bentler, 1976; Knorr et al., 1968; Lothstein, 1977a). Follow-up of patients
who have undergone surgery since 1953 has indicated that outcome is variable
depending on whether preoperative adjustment was primarily "heterosexual,"
"homosexual," or "asexual" (Bentler, 1976), and a number of transsexuals with
accompanying psychopathology have experienced psychotic decompensation,
reversal of the cross-gender identity, or suicidal depression after surgery
(Van Putten and Fawzy, 1976). Study of these cases has suggested that
diagnostic criteria have not been adequately specified and assessment
procedures have not been adequately standardized or rigorously applied save
for a few exceptions (Money and Primrose, 1969).
Because outcome and follow-up studies of different treatment approaches are
lacking (Stoller, 1973; Van Putten and Fawzy, 1976), it is unclear which is
the treatment of choice for which transsexual subgroup. Only behavioral
interventions have been systematized, well documented, and replicated to date.
Gender reorientation with surgical sex reassignment has been reported to
improve self-concept, social/vocational functioning, and stress tolerance
(Benjamin, 1967; Friedman et al., 1976; Money, 1971; Pauly, 1968; Randell,
1971; Satterfield, 1981). All surveys have claimed variability of outcome,
and severe failures occur (Money and Wolff, 1973; Randell, 1971; Sturup, 1976;
Van Putten and Fawzy, 1976). Child intervention for gender dysphoria and
atypical behaviors appears quite effective and may be of use as a preventive
tool.
Given these preliminary indications that adult transsexualism takes
different forms and is mutable, the following recommendations are suggested:
1. A concentrated effort should be made to gather follow-up data for
specific transsexual subgroups, using behavioral checklists, measures of
cross-gender identification, sexual fantasy material, and measures of
personality organization. Follow-up data should be gathered at initial
assessment, early in psychotherapy, at half-year intervals, and at 1-, 3-, and
5-year intervals if possible in adults, assessing changes in social,
vocational and psychological functioning for use in establishing a current
treatment of choice.
2. Longitudinal studies of gender-deviant children should be instituted to
establish more clearly the relationship between childhood gender role and
adult gender identity and sexual partner choice. Comparable follow-up for
treated children should be conducted using standardized assessment instruments
and intervals to yield further data on the utility of primary prevention.
3. Transsexual subgroups must be examined in terms of associated
personality organization and psychosocial and sexual history. Standardized
psychological assessment would clarify the presence and nature of accompanying
psychopathology.
4. Selection criteria for surgical sex reassignment must be refined in
light of findings that some transsexuals with severe psychopathology
deteriorate further after surgery. Reassignment procedures must be rigorously
denied whenever surgery is considered to present this risk.
5. Return to an extremely conservative position regarding when to grant
sex reassignment surgery is advocated. Surgery should be performed only at
hospitals under the auspices of well planned gender identity research
projects, and no surgery should be performed without a detailed plan of
follow-up.
6. Diagnostic instruments specifically intended for the measurement of
gender identity and gender role must be developed and validated against other
currently existing measurement procedures.
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