A psychological comparison of heterosexuals, transvestites, preoperative transsexuals, and postoperative transsexuals

The psychological functioning of male heterosexuals, transvestites, preoperative transsexuals and postoperative transsexuals was assessed. The groups represented a gradient of progressive feminization which showed progressive levels of psychological dysfunction. The data indicated that the transsexuals studied were indicative of a select group demonstrating profound psychological dysfunction. The study contributes to the recent literature, which indicates that sex reassignment surgery for this group is not the treatment of choice. Criteria for projecting postoperative outcome are outlined which can be utilized to direct gender dysphoria patients to alternate treatments.     

Transsexual subtypes: clinical and theoretical significance

The present study was designed to investigate whether transsexuals can be validly subdivided into subtypes on the basis of sexual orientation, and whether differences between subtypes of transsexuals are similar for male-to-female (MF) and female-to-male transsexuals (FMs). Within a large transsexual sample (n = 187), homosexual and nonhomosexual subjects were compared on a number of characteristics before the start of treatment. Differences within MF and FM groups were also investigated. Homosexual transsexuals were found to be younger when applying for sex reassignment, reported a stronger cross-gender identity in childhood, had a more convincing cross-gender appearance, and functioned psychologically better than nonhomosexual transsexuals. Moreover, a lower percentage of the homosexual transsexuals reported being (or having been) married and sexually aroused while cross-dressing. The pattern of findings was different for MFs and FMs. No differences between homosexuals and nonhomosexuals were found in height, weight, or body mass index. A distinction between subtypes of transsexuals on the basis of sexual orientation seems theoretically and clinically meaningful. The results support the notion that in the two groups different factors influence the decision to apply for sex reassignment. The more vulnerable nonhomosexual transsexuals may particularly benefit from additional professional guidance before and/or during treatment.     

Comments on the paper “Men as women” by Stig-Eric Olsson,Inge Jansson,and Anders Möller

A worldwide pool of data indicates a successful outcome in transsexuals who have been carefully selected for sex reassignment. Outcome has improved over the years owing to, among other things, more restricted inclusion criteria.     

Defensive functioning in MtF and FtM transsexuals

In spite of the potential clinical utility of defense mechanisms in the assessment of gender identity disorder patients as candidates to sex reassignment surgery, there is paucity of research in this field. The aim of the present study is therefore to ascertain whether the defensive profile of MtF and FtM transsexuals seeking sex reassignment surgery can be defined more primitive, immature and maladaptive than that of the two control groups. We compared the defensive profiles as assessed through the REM-71 (Steiner et al., 2001) of 104 MtF transsexuals, 46 FtM transsexuals and two control groups of males and females.     

Clinical characteristics of a total cohort of female and male applicants for sex reassignment: a descriptive study

The objective of this study was to compare the features of female-to-male transsexuals (F-M) with those of male-to-female transsexuals (M-F) in the cohort of all applicants for sex reassignment over a 20–year period. In an observational, cross-sectional design the cohort was retrospectively identified, consisting of all 233 subjects who applied for sex reassignment in Sweden during the period 1972–1992. The cohort was subdivided into the groups M-F (n=134) and F-M (n=99), and the two groups were compared. M-F were older when applying for sex reassignment surgery than F-M, and more often had a history of marriage and children than their F-M counterparts. M-F also had more heterosexual experience. F-M, on the other hand, more frequently exhibited cross-gender behaviour in childhood than did M-F transsexuals. The present and previous studies strongly support the view that transsexualism manifests itself differently in males and females. Various models for understanding these differences are discussed.     

Factors predictive of regret in sex reassignment

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.     

Transsexualism: a review of etiology, diagnosis and treatment.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.     

Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study

OBJECTIVE: To conduct a prospective follow-up study with 20 treated adolescent transsexuals to evaluate early sex reassignment, and with 21 nontreated and 6 delayed-treatment adolescents to evaluate the decisions not to allow them to start sex reassignment at all or at an early age. METHOD: Subjects were tested on their psychological, social, and sexual functioning. Follow-up interviews were conducted from March 1995 until July 1999. Treated patients had undergone surgery 1 to 4 years before follow-up; nontreated patients were tested 1 to 7 years after application. Within the treated and the nontreated group, pre- and posttreatment data were compared. Results between the groups were also compared. RESULTS: Postoperatively the treated group was no longer gender-dysphoric and was psychologically and socially functioning quite well. Nobody expressed regrets concerning the decision to undergo sex reassignment. Without sex reassignment, the nontreated group showed some improvement, but they also showed a more dysfunctional psychological profile. CONCLUSIONS: Careful diagnosis and strict criteria are necessary and sufficient to justify hormone treatment in adolescent transsexuals. Even though some of the nontreated patients may actually have gender identity disorder, the high levels of psychopathology found in this group justify the decision to not start hormone treatment too soon or too easily.     

Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent

 Early cross-sex hormonal interventions (that is, between 16 and 18) as a treatment for young transsexuals are often considered to be risky. However, the delay of such treatment until after the development of secondary sex characteristics has obvious drawbacks for transsexual individuals. This paper reports a postoperative follow-up case-study of a female-to-male transsexual who was treated with a combination of an LHRH agonist (which delayed her secondary sex characteristics development) and psychotherapy at age 13, and subsequently underwent sex reassignment at 18. Accepted: 8 June 1998     

Le test de Rorschach et la pensée opératoire dans l'approche théorique du transsexualisme

The authors studied the outcome of Rorschach tests on 28 transsexuals who had applied for sex reassignment surgery. The results were analysed on a 63-item grid. The transsexuals and the control group were matched by biological sex, age and education level. For the interpretation of the results, the authors refer to: a)- psychodynamic theory (C. Chabert); b)- L. Cassier's symbol elaboration index (SEI); c)- some aspects of the Exner method. The various indexes produce significant figures: - Subject's very low SEI levels suggests a defect in symbolization capacity bringing their mental processes close to those of operatory thought: i)- a deficit in emotional control (CF + C>FC); ii)- the passive movements count (Kau+K) is higher than the active movements count (Snow White index confirmed), signifying a tendency to look to others to resolve problems in reality. What are the applications of this new approach to transsexualism? We find the elements of operatory thought dear to P. Marty to be characteristic of the mental functioning of transsexuals: difficulty in feeling and expressing emotional states, life of the imagination reduced to the factual, and concretely-oriented thought processes. Operatory thought can be constituent of the development of the ego and be rooted in the essentiel depression of the infant. It may also represent an “extreme” defence mechanism against an “extreme” threat endangering the ego. In this case it may be only transitory and open to evolution. This psychosomatic model directly influences the accompaniment of patients who would benefit, in psychotherapy, from help in gaining better access to symbolization.     

Sex reassignment and other kinds of treatment in case of transsexualism

This report discusses the recent literature on the sex reassignment and psychotherapy in the case of patients with transsexualism. On the basis of a literature review, the author provides guidelines for evaluating, referring to and treating patients who request surgical operation (e.g. hormonal reassignment, monitored "real life test"). Medical and psychological risk of the sex surgery is indicated. The status of psychotherapy in the treatment of severe gender dysphoria (transsexualism) is also presented. Psychoanalytical, behavioral or cognitive therapy is rather rarely recommended as the possible alternative in the treatment of transsexuals. Sometimes psychotherapy is included as a part of treatment both before and after surgery. Although the outcomes of the sex surgery still remain unclear it is a widely used method of curing transsexualism.     

Prediction of regrets in postoperative transsexuals

This study investigated whether heterosexual males are more likely to regret sex reassignment surgery than homosexual males or females. Subjects were 111 postoperative transsexuals who had been surgically reassigned for at least one year, representing a follow-up rate of 84.1%. Subjects' feelings about surgery were assessed with self-administered questionnaires. None of the 61 homosexual females or 36 homosexual males consciously regretted surgery, compared to 4 of the 14 heterosexual males: a significant difference. This finding suggests that heterosexual applicants for sex reassignment should be evaluated with particular caution, although a heterosexual preference is not an absolute contraindication for surgery.     

Behandlungverläufe transsexueller Patienten Eine katamnestische Untersuchung

In a retrospective study, 33 transsexual patients, 22 male-to-female transsexual (MF-TS), and 11 female-to-male transsexuals (FM-TS), were interviewed 53-121 months after their first referral to the psychiatric department of a university hospital. Social integration proved to be satisfactory and relatively stable. Twenty-five patients had gone through surgical sex reassignment, while 29 were currently undergoing hormonal treatment. Regarding the course of treatment, the FM-TS were a more homogeneous group than the MF-TS group. Overall, physical and psychosocial well-being was satisfactory. Psychometric measures yielded remarkably normal values, with some pathological findings regarding personality traits. In the majority of patients, self- and observer-rating appraisals of gender-specific physical appearance were equally positive. The results suggest a three-step procedure for the treatment of transsexual patients, as is practiced in other centers within German speaking continental Europe.     

Male transsexuals: a long-term follow-up after sex reassignment operations.

Since 1953 the Danish law permitting castration has been applied to transsexuals. Case histories are here reported on ten cases, operated up to 19 years before the follow-up. Six of these presented typical syndromes. In some of the early cases the reluctance on the part of therapists to adopt an active therapy has been too great. Two subjects had died before the follow-up investigation, but both had formerly reported satisfaction with the treatment to their therapists. One case- happily married - had emigrated with the husband. At the interviews the three others confirmed happiness and satisfaction with their female way of life. They are living in resonably good social circumstances. Three cases were not typical. A promiscuous massive sexual activity exhibited by these patients had made it very difficult to endorse a surgical solution to their strongly presented with to obtain sex reassignment. At the follow-up all three were very satisfied with their female role. After several years in their new sex role, two of these were still promiscucos. The last case presents unusually complicated sex role problems. He continues to live as a male, but he still insists 19 years after castration, that the operation saved his life. In spite of his handicap, he claims to be satisfied that he obtained the permit. None of the operated cases committed suicide, but one case - not operated but living as a female - developed a paranoid reaction resulting in suicide.     

The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI study

Background

Diffusion tensor imaging (DTI) has been shown to be sensitive in detecting white matter differences between sexes. Before cross-sex hormone treatment female to male transsexuals (FtM) differ from females but not from males in several brain fibers. The purpose of this paper is to investigate whether white matter patterns in male to female (MtF) transsexuals before commencing cross-sex hormone treatment are also more similar to those of their biological sex or whether they are more similar to those of their gender identity.

Method

DTI was performed in 18 MtF transsexuals and 19 male and 19 female controls scanned with a 3 T Trio Tim Magneton. Fractional anisotropy (FA) was performed on white matter of the whole brain, which was spatially analyzed using Tract-Based Spatial Statistics.

Results

MtF transsexuals differed from both male and female controls bilaterally in the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract.

Conclusions

Our results show that the white matter microstructure pattern in untreated MtF transsexuals falls halfway between the pattern of male and female controls. The nature of these differences suggests that some fasciculi do not complete the masculinization process in MtF transsexuals during brain development.     

Sex reassignment surgery in Europe: a survey

Since the first publications on a sex reassignment operation in Denmark in the early fifties, the European environment in which sex reassignment surgery (SRS) takes place has changed drastically. However the possibilities differ considerably between one country and another. To get a picture of the European situation a questionnaire was sent out to gender clinics and private practitioners treating transsexuals in 15 European countries. Questions were asked about evaluation of candidates for a treatment program, details of such programs, the legal and financial situation in the different countries and attitudes and place of psychotherapy in the SRS procedure. By and large there seems to be fairly good consensus within those European SRS treatment programs we had the opportunity to evaluate.     

The prevalence of transsexualism in Singapore

The prevalence of transsexualism in Singapore was estimated by counting all the patients who sought sex-reassignment surgery and were subsequently diagnosed as transsexuals by psychiatrists. Up to 1986, there were a total of 458 Singapore-born transsexuals, of which 343 were males and 115 were females. This was a prevalence of 35.2 per 100,000 population age 15 and above (or 1/2900) for male transsexualism, and 12.0 per 100,000 (or 1/8300) for female transsexualism. The sex ratio was about 3 males to 1 female. The main reason for the high prevalence was the availability of sex-reassignment surgery.     

Incidence and sex ratio of transsexualism in Sweden

Landén M, Wålinder J, Lundström B. Incidence and sex ratio of transsexualism in Sweden. Acta Psychiatr Scand 1996: 93: 261–263. © Munksgaard 1996. The incidence and sex ratio of transsexualism in Sweden were calculated during the period between 1 July 1972 and 30 June 1992 using a case register kept on file at the Swedish Bureau of Social Welfare. Only cases of primary/genuine transsexualism were considered. The study is unique in that it has been performed in exactly the same way as a previous study by one of the authors (JW) in the 1960s and early 1970s. The data can therefore be reliably compared. The results show that the incidence figures remain constant over time and that the incidence of primary/genuine transsexualism is equally common in men and women. A larger group consisting of all those individuals who had applied for sex reassignment revealed a preponderance of men. Analysis showed that this large group included not only primary/genuine transsexuals but also effeminate homosexuals, transvestites and diagnostically uncertain cases. The importance of describing the exact methods used when calculating epidemiological data is highlighted.     

Adolescents with gender identity disorder: reconsideration of the age limits for endocrine treatment and surgery

The third versions of the guideline for treatment of people with gender identity disorder (GID) of the Japanese Society of Psychiatry and Neurology does not include puberty-delaying hormone therapy. It is recommended that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 year old and 20 year old, respectively. On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender nonconforming people of World Professional Association for Transgender Health (WPATH) recommend that transsexual adolescents (Tanner stage 2, [mainly 12-13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which cross-sex hormones may be given. A questionnairing on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) transsexuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) transsexuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent cross-gender identification, adolescents with GID should be treated with cross-gender hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transsexual adolescents from attempting suicide, being depressive, and refusing to attend school. Subsequent early breast and genital surgery may help being employed in desired sexuality.     

White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study

Background

Some gray and white matter regions of the brain are sexually dimorphic. The best MRI technique for identifying subtle differences in white matter is diffusion tensor imaging (DTI). The purpose of this paper is to investigate whether white matter patterns in female to male (FtM) transsexuals before commencing cross-sex hormone treatment are more similar to that of their biological sex or to that of their gender identity.

Method

DTI was performed in 18 FtM transsexuals and 24 male and 19 female heterosexual controls scanned with a 3 T Trio Tim Magneton. Fractional anisotropy (FA) was performed on white matter fibers of the whole brain, which was spatially analyzed using Tract-Based Spatial Statistics.

Results

In controls, males have significantly higher FA values than females in the medial and posterior parts of the right superior longitudinal fasciculus (SLF), the forceps minor, and the corticospinal tract. Compared to control females, FtM showed higher FA values in posterior part of the right SLF, the forceps minor and corticospinal tract. Compared to control males, FtM showed only lower FA values in the corticospinal tract.

Conclusions

Our results show that the white matter microstructure pattern in untreated FtM transsexuals is closer to the pattern of subjects who share their gender identity (males) than those who share their biological sex (females). Our results provide evidence for an inherent difference in the brain structure of FtM transsexuals.