Susan's Place Transgender Resources for Transsexuals and Crossdressers: Library: Sex Reassignment Surgery: Historical, Bioethical, and Theoretical Issues spLoadMenus();                    We stand at the crossroads of gender balanced on the sharp edge of a knife.***From FEMINET, Felton CA 408-335-4387 or 408-335-7888Sex Reassignment Surgery: Historical, Bioethical, and Theoretical Issues By Leslie M. Lothstein, Ph.D. The reported 68% - 86% overall success rates for sex reassignment surgerymust be viewed cautiously; the lack of long-term follow-up studies makes thesestatistics misleading. There is evidence suggesting that some genderdysphoric patients benefit primarily from sex reassignment surgery. Most suchpatients, however, are secondary transsexuals who can benefit from variousmodes of psychotherapy. Sex reassignment surgery should only be considered asthe last resort for a highly select group of diagnosed gender dysphoricpatients. As physicians learn new ways to diagnose and treat transsexualism,either sex reassignment surgery will be abandoned as a routine treatmentmodality or new predictive variables for choosing suitable patients for sexreassignment surgery will be established. Received Oct. 10, 1980; accepted Dec. 23, 1980. From the Department of Psychiatry, University Hospitals of ClevelandAddress reprint requests to Dr. Lothstein, University Hospitals of Cleveland,2040 Abingdon Rd., Cleveland, OH 44106. Few psychiatric issues have stirred up as much controversy and emotionalturmoil as transsexualism and sex reassignment surgery. Those clinicians whoespouse sex reassignment surgery as a legitimate form of treatment view iteither as a palliative or a cure of the gender dysphoric patient's intensesocial-psychological suffering. Most clinicians who recommend sexreassignment surgery as the treatment of choice also tend to believe thatpsychotherapy is useless with gender dysphoric patients. In support of theirview, they cite several positive follow-up studies on postoperativetranssexuals (1-3) and the American Medical Association Commission on HumanSexuality's 1972 sanction of sex reassignment surgery as the treatment ofchoice for diagnosed transsexuals (4). Moreover, a recent book, Controversyin Psychiatry, mentioned sex reassignment surgery as a viable treatmentmodality for selected patients in a medical center (5). On the other hand, those clinicians who consider sex reassignment surgeryas an illegitimate form of medical-surgical treatment usually characterize itas mutilative and antitherapeutic. They point to the complex psychological,medical, legal, bioethical, and political issues that are neglected orbypassed by sex reassignment surgery procedures. They argue that sexreassignment surgery leads to mistreatment and mismanagement of the genderdysphoric patient. In one study a majority of the 300 physicians queriedopposed sex reassignment surgery for transsexuals (6). In support of theirview, clinicians cite studies indicating that various modes of psychotherapycan successfully stabilize the gender dysphoric patient short of sexreassignment surgery (7-9). These studies suggest that some clinicians mayhave prematurely accepted Hertz and associates' dictum that "transvestism [nowcalled transsexualism] resists psychiatric treatment" (10). The debate among mental health practitioners has recently been fueled bythe closing of the Johns Hopkins Gender Identity Clinic (11) and by severalstudies supporting sex reassignment surgery (reference 12 and an unpublishedstudy by S. Satterfield). Arguments both for and against sex reassignmentsurgery, however, are based more on rhetoric than on hard evidence. Those whobelieve sex reassignment surgery is beneficial for certain patients mustacknowledge the lack of hard empirical evidence supporting their views and thelack of even acceptable diagnostic criteria for selecting good candidates forsex reassignment surgery. Those who argue against sex reassignment surgerymust account for the reported wide spread patient satisfaction with theprocedures and evidence of resulting positive life changes. While DSM-IIIaddresses some of the confusing diagnostic issues among the gender identitydisorders, the new criteria do not deal with treatment issues. In additionthere are no standards for the medical-psychological care of patients withprofound gender dysphoria (transsexualism). As more and more patients requestsex reassignment surgery, the issue of appropriate treatment for them becomescentral. Indeed, ever since the sensationalism of the Christine Jorgensoncase (13), large numbers of patients have requested information regarding sexchange (14, 15). A combination of several factors - the availability ofsurgery, media exposure, the existence of national and international referralcenters and information sources, and the establishment of many gender identityclinics - has made it necessary for clinicians to take a stand for or againstsex reassignment surgery. Of the currently estimated 30,000 transsexuals, as many as 10,000 may beresiding in the United States (16). One researcher, Prince (17), has evensuggested that the number of requests for sex reassignment surgery has reachedepidemic proportions. Indeed, a 1977 report estimated that over 1,000surgical procedures would be performed in the United States in 1980 (16). Aslong as there are no universally accepted standards of care, hospitals caneither prohibit sex reassignment surgery or make it routinely available togender dysphoric patients on a fee-for-service basis. If sex reassignmentsurgery becomes a Medicaid-subsidized procedure, it could be performed on manynontranssexual patients with gender dysphoria, who may later regret theirdecisions. While all practitioners should be concerned about the unrestricteduse of sex reassignment surgery, it may be that for some patients sexreassignment surgery is the treatment of choice. Those clinicians who espousesex reassignment surgery, however, must determine which gender dysphoricpatients are the best candidates for the procedure. In spite of the many clinical research studies of transsexualism, verylittle is actually known about the medical-surgical and social-psychologicaleffects of sex reassignment surgery. Many questions are left unanswered. Forexample, which, if any, patients derive the most benefit from sex reassignmentsurgery? What data support the continued use of sex reassignment surgery as atreatment regimen? What is the crucial test for determining the prescriptionof sex reassignment surgery? To my knowledge there has not been a single comprehensive review of thepublished sex reassignment studies or an analysis of their results. It is theaim of this paper to address these issues by reviewing and examining thehistorical roots, assumptions, and findings of the major studies. In thiscontext, suggestions for future research strategies and directions fortreatment will be made. SEX REASSIGNMENT SURGERY THROUGH THE 1960s The historical, cultural, anthropological, and literary development ofsexual transformation and surgery is well documented (18-21). Green (22)cited incidences of sexual transformation procedures in early Greek andclassical history, the Renaissance, and modern times: cultural examples fromAmerican Indian tribes as well as Indo-European and Asiatic cultures areincluded. Throughout history instances of autocastration and genitalmutilation, the result of an individual's intense desire to change sex havebeen reported (23). Translating the desire for sex reassignment surgery intoa reality, however, required the advances of modern surgical technology andhormonal procedures. In the following reviews of surgery follow-up, thestudies are reported chronologically. While Abraham (24) reported on the first sex reassignment surgery of twomale transvestites in 1931, it was not until the publication of Lilly Elbe'sautobiography (25) that sex reassignment surgery became a popular andpractical solution for the transsexual's dilemma. The first significant postsurgical findings were reported by Hertz andassociates (10). That study investigated the postsurgical functioning of 2male and 3 female transvestites (including one who changed back to his malerole after 7 years). The mean postsurgical period was 7.8 years (range = 3.5to 16 years). Follow-up data on 4 patients' social-emotional states suggestedsatisfactory outcome. The evaluative criteria were based on the impressionsof the investigators. A review of the findings suggests some discrepancieswith usual clinical assessment in that one patient who was judged to have asatisfactory outcome was actually a depressed drug addict who engaged inhomosexual prostitution. The beginning of serious research in the field was initiated with thepublication of Benjamin's classic follow-up study (1) of postoperativetranssexuals. Of 73 men and 20 women who underwent surgery, 85% of the men (N= 62) and 95% of the women (N = 19) showed satisfactory outcomes. Thesefigures were derived by classifying postsurgical patients into threecategories: unsatisfactory, good, and satisfactory. The assignments werebased on impressionistic evidence, patients' self-reports, and anecdotalmaterial about the patients' postsurgical social-biological-psychologicalstatus. There were no attempts to obtain standardized data from each patient;no demographic data were provided. The overall 87% improvement figureincluded patients in both the good and satisfactory groups. Money and Brennan's study (26) of 6 postsurgical women corroboratedBenjamin's findings. They concluded that "the evidence to date is that sexreassignment does indeed improve the human condition of the afflictedindividual." However, neither of these studies separated the male and femalegroups on any basis whatsoever. Since most theoreticians regard femaletranssexualism as diagnostically and dynamically distinct from maletranssexualism (27), one would expect that such a methodological error couldlead to faulty conclusions. In his 1968 review (28) of the world literature on 121 cases, Paulyconcluded that a group of transsexuals who underwent sex reassignment surgerywas 10 times more likely to have a satisfactory outcome, in terms of socialand emotional status, than a group who did not. These findings have providedthe bedrock for continued support of sex reassignment surgery. Randell (2) reported postoperative results on 29 men and 6 women(postsurgical follow-up ranged from 3 months to 7 years). According to themale and female adjustment ratings (including acceptability as a male orfemale, subjective satisfaction, social adaptation, and physician'sassessment), 72% of the men and 83% of the women had satisfactory outcomes.Although 2 men committed suicide, Randell concluded that the patientsdemonstrated lessened environmental conflicts, significantly decreased levelsof anxiety and depression, and improvements in family relations andemployment. The studies of the 1960s ended on a less positive note as Golosow andWeitzman (29) reported on a single case involving a man who was hospitalizedwith severe depression and regressed behavior 15 months after sex reassignmentsurgery. The patient had been provided with sexual surgery despite the lackof a life long gender conflict. Benjamin (1) had previously described a caseof a 56-year-old man who expressed regret after surgery and was laterreassigned back to his male role. Money and Primrose (30) reported that none of their 12 postoperative maletranssexuals exhibited a maternal response. This finding was amplified byNewman and Stoller (31), who hypothesized that male transsexuals are notcapable of achieving womanhood, since they have not experienced the usualdevelopmental pathways and oedipal conflicts of biological girls and onlyexhibit surface-shallow female characteristics. They concluded that althoughsurgery may change a person's secondary sexual characteristics, the inner maleor female identity remains untouched. Unfortunately, no further analyses ofthe inner psychological feelings of postoperative transsexuals were performed. Summary With one exception the follow-up studies up to and throughout the 1960sfocused entirely on gross social-psychological measures of improvement. Theconsensus of these studies was that sex reassignment surgery was the treatmentof choice for transsexualism. In spite of a few negative outcomes involvingsuicide (2), psychiatric disturbances (30), and role re-reversal (1), mostinvestigators were optimistic about sex reassignment surgery. Citing an 80%-90% cure rate for sex reassignment surgery, investigators generally acceptedthe fact that traditional psychiatric intervention was useless withtranssexuals and that sex reassignment surgery was the treatment of choice fortranssexualism. However, clinicians outside the area of transsexual researchwere not so accepting of these conclusions (32). SEX REASSIGNMENT SURGERY THROUGH THE 1970s Throughout the 1970s increasing numbers of patients sought sex reassignmentsurgery. Many of these patients were secondary transsexuals who, understress, expressed a regressive wish for sex reassignment surgery. Spurred onby changing views of societal sex roles, large numbers of patients were givenexternal support to change their sex rather than to understand the nature oftheir psychological distress. Moreover, lacking a formal schema to diagnosegender dysphoric conflicts and lacking standards of medical-surgical care, theprofession of psychiatry was unprepared to adequately respond to thetranssexual's dilemma. In addition, since sex reassignment surgery wasavailable to almost any self-labeled transsexual who could pay the fee and thesurgery was often performed secretly, few of them were available for followup. There was little that psychodynamically oriented psychotherapists coulddo to intervene using psychological methods. In spite of the many difficulties outlined, the initial studies of theresults of sex reassignment surgery in the 1970s widened the criteria forinvestigating the postsurgery patient and contributed significantly toadvances in our knowledge of gender identity disturbances. In the apparently first published study of the 1970s, Money and Ehrhardt(33) investigated 17 men and 7 women and compared the patients' preoperativeand postoperative adjustment along five dimensions: capacity for a lastingrelationship with a partner, adjustment to work, criminality, mental state,and patients' subjective opinion of the result. Only one woman was reportedlydissatisfied with the cosmetic results, but she stated that she would undergothe procedure again. The patients' satisfactory adjustment on all levels ledto the conclusion, "If one is able to stipulate specific criteria for sexreassignment surgery, then it can be seen that the outcome of sex change, thatis, the psychological and social situation of transsexuals, is oftentimesbetter than worse" [my translation]. The conclusion was somewhat illusory inthat no universally acceptable criteria for patient selection were provided. In the second study of the 1970s, Hoenig and associates (34) reviewed theliterature on sex reassignment surgery and reported on a follow-up study of 8of their own patients (5 men and 3 women). One of the women and 4 of the menwere judged to be psychiatrically disturbed; 1 of the men had had a leucotomy.Although 1 patient was judged to have a poor outcome, none of the patientsexpressed regret over the surgery. The 12% failure rate supported theauthors' conclusion that "the treatment helps the majority of patients bothsubjectively and objectively... but the operation can in no sense be regardedas a cure." This was the first study to acknowledge the high incidence ofpsycho-pathology among postoperative transsexuals and challenged the notionthat sex reassignment surgery could cure the transsexual's distress. Indeed,2 years later Money and Wolff (35) reported on a male transsexual whosepostoperative depression was so severe that he was later reassigned to hismale role. They attributed the poor results to a deficient presurgicalevaluation. The possibility of surgery's proving harmful has been supportedby a number of single case studies (36-38). At Northwestern Medical Center Arieff (39) studied 14 men and 4 women for 5years after surgery. The group included 3 blacks and 1 Oriental. Ninepatients (50%) demonstrated better social adjustment; 2 patients (11%) hadbetter vocational adjustment; 5 (28%) improved their relationships by gettingmarried; and overall conditions worsened for 2 patients (11%). While theamount of overlap among the groups is unclear, it is apparent that themajority of patients were not cured. While Gandy (40) supported the use of objective criteria to assess outcome(social and economic improvement and subjective feeling of happiness), hisreport of the preliminary findings of the Stanford group indicated thatsurgery on demand would probably be disastrous. Unfortunately, he did notelaborate on this view. On the other hand, Ihlenfeld's review (41) of Benjamin's findings indicatedthat most adult transsexuals achieved good results with sex reassignmentsurgery (although 5 of the patients died from mysterious drug-relatedaccidents). Ihlenfeld's optimism about sex reassignment surgery led him toargue for the possible surgical benefits for transsexual patients in their 50sand 60s. Hastings and Blum (42) reported on 25 men who received sex reassignmentsurgery at the University of Minnesota. Using a college grading system (A, B,C, and D), they rated patient outcome on sexual, economic, and socialvariables. Twelve patients experienced multiple orgasms; 12 patients weremarginally self-supportive; 8 were on welfare; 10 patients were married,including 6 who had remained with their original spouses. Despite 1 whoattempted suicide, satisfactory adjustment was reported for all the patients.There was no indication of the degree of overlap among the variables of changeinvestigated. One case warrants reporting in detail because of itsconsequences. In that case a patient who mutilated his genitals and had aprison record was eliminated as a surgical candidate. The patient's threat ofsuicide, however, prompted Hastings and Blum to bring in six outside judgesfrom Minneapolis. The judges urged the clinic to perform surgery: 1 monthafter surgery the patient reverted to living as a man. In another instanceone of their clinic staff members recommended 5 psychopaths for sexreassignment surgery to see if this procedure would cure their characterproblems. He eventually concluded that sex reassignment surgery is not a curefor psychopathy. Laub and Fisk (43) reported on 74 patients - 50 men and 24 women - whoreceived sex reassignment surgery. (At the 1980 APA annual meeting theStanford team updated their statistics, reporting that 131 men receivedvaginoplasty, 75 women received phalloplasty, and 86 women receivedmastectomies.) Thirty-eight of the men had surgery at Stanford. Theyevaluated patients' employment, social-psychological, and sexual adjustmentusing a grading system similar; to that used by Hastings and Blum. Fivepatients were unavailable for follow-up. Although 1 patient regretted havingsurgery and another committed suicide, they concluded that sex reassignmentsurgery did not significantly harm any patients. They reported significantimprovement in all but the psychological areas of functioning. This study isimportant because the surgical group included nontranssexuals, e.g.,effeminate homosexuals and transvestites, and the researchers separated thepsychological from the social domain. The term "gender dysphoria syndrome"was used to describe patients who requested sex reassignment surgery. Lauband Fisk concluded that "transsexuals are not the only group that can benefitfrom this type of surgery." Preoperative behavioral adaptation to the newgender role, not psychiatric diagnosis, was found to be the best predictor ofpostsurgery outcome. This was apparently the first study that mentioned sexreassignment surgery as a treatment for nontranssexual disorders. At the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome,Fisk (44) reported on the postsurgical follow-up of eight men who had beendiagnosed as psychotic or schizophrenic (with delusions focusing on sexualidentity). Their postoperative improvement was so marked that Fisk labeledthem "eight spectacular cases"; the number has recently been reduced to 5(45). Fisk felt that sex reassignment surgery could result in remission forsome psychotic or schizophrenic individuals whose disturbances focused mainlyon sexual identity. Prior to this report, all surgical centers had refused tooperate on schizophrenic or psychotic patients. Schizophrenic patients withdelusions of sex change had been known to request sex reassignment surgery(46). The suggestion that sex reassignment surgery might prove beneficial forschizophrenic patients represented a major departure from current thinking. Gottleib (47) reported on the follow-up of 9 transsexuals, including 1 whowas left decorticate secondary to anesthesia, 1 who was postoperativelylabeled a "freak," and a 23-year-old male-to-female patient who adopted alesbian role after surgery. Biber (48) reported on 1 schizoid patient who wasin the process of being reassigned back to his biological maleness. In lightof these poor outcomes, a well-known author and transvestite, Virginia Prince,suggested that more attention be paid to nonsurgical alternatives fortranssexuals, noting that, at least in California, "sex reassignment surgeryis a communicable disease" (personal communication, 1977). Hore and associates (49) reported on 16 English transsexuals who werestudied for 6 to 18 months after surgery. For 11 patients (69%) the surgerywas judged beneficial, i.e., they felt more feminine, had increasedconfidence, and were emotionally and sexually better adjusted; 2 of themmarried. However, 5 patients expressed dissatisfaction; 3 were dissatisfiedwith the cosmetic results, and 2 did not feel completely female. Eight of the11 patients (73%) had long histories of psychiatric illness. These resultswere consistent with the findings of Hoenig and associates (34). Money (50) reported on one of the youngest patients to have sexreassignment surgery. The patient was a male twin whose penis had beenamputated secondary to an accident during circumcision. The child wassurgically revised to a female at age 17 months and is being raised as a girl.Recent follow-up suggests a good outcome. In a study conducted at Vanderbilt University, McKee (51) reported on 7 menand 4 women who had received surgery but did not provide detailed notes ontheir social-psychological condition. Walinder and Thuwe (3) conducted the most comprehensive follow-up study todate. They examined the social-psychiatric histories of 24 reassignedtranssexuals; detailed histories for each patient were included in the report.Eleven men and 11 women were available for follow-up; 2 men were not. Theyexpanded on Money and Ehrhardt's five follow-up criteria (33) by elaboratingon the social aspects, e.g., place of residence, Social Security benefits,alcoholism, criminality, periods of certified sickness, and disabilitypensions. Other adjustment criteria included sexual life (propensity andstrength), housing conditions, attitudes of relatives, work records, patients'subjective opinion, and investigators' assessment (including psychologicalstate and appearance). By studying their patients at least 3 yearspostoperatively, they tried to eliminate the usual immediate postsurgery haloeffect. They found that the biological females generally had a betteroutcome; 2 men (18% of the men) regretted having surgery. Overall, 91% of thewomen and 69% of the men had satisfactory outcomes. These results areconsistent with those of Benjamin (1), Randell (2), and Money and Ehrhardt(33). The small sample size precluded the possibility of obtainingstatistically significant presurgery and postsurgery differences. Walinderand Thuwe concluded, Taking men and women together, the outcome was clearly favorable inapproximately 80% of the cases. The proportion of unsuccessful cases in ourseries is about the same as that found by Hoenig et al in a review ofpreviously published follow-up cases. When we considered the severe sufferingand the many difficulties experienced by untreated transsexuals in variousfields of life, the treatment programme appears to be fully justified bothmedically and ethically. Sturup (52) clinically evaluated 8 of 10 patients up to 19 years after sexreassignment surgery. Two had died; half of the remaining patients exhibitedsevere adjustment problems. All but 1 reported psychological problems,including difficulty at work, sexual maladjustment, depressive ideation,suicidal behavior, familial rejection, continuous living in the male role, andreactive psychosis. In spite of these difficulties, all of the patients weresatisfied with the surgical results. Lothstein (53) studied two groups of patients after sex reassignmentsurgery. Group 1, consisting of 7 biological males, had sex reassignmentsurgery before the establishment of a gender identity clinic at Case WesternReserve University Medical School. Group 11 (8 biological males and 6biological females) had surgery after intensive evaluation and long-termpsychological and medical treatment. The average postsurgery time span was1.9 years (range = 0.5 to 3.5 years). Systematic data were gathered on eachpatient in group 11 prior to surgery. Patients completed a 59-itemquestionnaire focusing on sexual, psychological, environmental, economic,parental, family, medical, and social adjustment and functioning. This wasapparently the first research study in which patient data were systematicallycollected and each patient was required to participate in intensivepsychological treatment. The results suggested moderate postsurgical social and sexual gainsaccompanied by marked depression and psychological confusion. However, allpatients reported being subjectively satisfied with the surgery. It wasconcluded that character structure and neurotic functioning are notpermanently altered by sex reassignment surgery. Moreover, all patientsshould be routinely provided counseling and/or psychotherapy to help themadjust to their new social-psychological status. Sex reassignment surgerydoes not facilitate the patient's psychological integration of gender role andidentity; this integration requires psychotherapy. A major conclusion of thisstudy was that all preoperative and postoperative gender dysphoric patientsshould undergo psychotherapy. In the most controversial study, Meyer and Reter (11) studied 100 patientswho applied for sex reassignment surgery at the Johns Hopkins Gender IdentityClinic. Of these, 34 underwent surgery (24 at Johns Hopkins and 10 elsewhere)and 66 failed to qualify for surgery. Only 15 of the 34 surgery patients (44%of the sample) were available for follow-up, 17 were lost to follow-up and 2refused to participate. Of the 66 nonsurgery patients (the control group), 35(53%) were available for follow-up and 31 were lost to follow-up. In summary,only 50% of the 100 patients were available for follow-up. Fourteen of the 35nonsurgery patients later received surgery, including 5 patients at JohnsHopkins; the remaining 21 patients were still interested in obtaining surgery.The surgery group (average age = 30 years) was studied for a mean of 5.0 years(range = 19-142 months); the nonsurgery group was followed for 2 years (range= 15-48 months). Four blacks were included in the group. Since there was no breakdown according to socioeconomic status, education,and race, the effect of interaction among these variables is unknown. Alldata except years of schooling were reported in percentages. The measuredvariables included change of residence; job and educational levels; priorpsychiatric treatment; and overall assessment score derived by using anarbitrary scaling method on legal, economic, marriage, cohabitation, andpsychiatric histories. Psychotherapy was not provided, and there was littleinformation on psychological functioning. While there were no statisticallysignificant differences among the initial adjustment categories, the trendsdid suggest that the surgery group showed the greatest changes over time.This finding was not elaborated on. Meyer and Reter concluded that "sexreassignment surgery confers no objective advantage in terms of socialrehabilitation although it remains subjectively satisfying to those who haverigorously pursued the trial period and who have undergone it." As a resultof a press release, these findings were used as evidence to close the surgicalprogram at Johns Hopkins. In the last analysis, the decision seemed to be theresult of political pressure and not to be based on the empirical findings ofthe study. Hunt and Hampson (12) reported on the follow-up of 17 biological males(mean of 8.2 years after surgery). While the patients reported gains insexual satisfaction, family acceptance, economic functioning, andinterpersonal relationships, there were no changes in the incidence ofpsychopathology. Although none of the patients regretted having the initialsurgery, 24% still felt a "driven need for further surgical procedures." Theauthors concluded that for a select group of transsexuals, "surgery willcontinue to offer... the best means of coping with this dilemma." Theycautioned, however, that sex reassignment surgery does not alter personality;the best predictors of postsurgical success are presurgical ego strength andpatients' "adjustment during the presurgery period while living in their newgender/sex role." At the 1980 APA annual meeting in San Francisco, Satterfield (unpublishedstudy) reported the preliminary findings of a follow-up of the original groupdescribed by Hastings and Blum. The 22 postoperative transsexuals included 3female-to-male patients (average postsurgery period = 3.8 years) and 19 maleto-female patients (average postsurgery period = 9.2 years). All patientsagreed to the interview and assessment and gave favorable responses about thesurgery on the structured interview and psychological assessment tasks.Patients were physically examined by a psychiatrist also trained in plasticsurgery, were given a battery of psychological tests including the MMPI, SCL-90, and Zung depression inventory, and were asked to complete an elaboratequestionnaire. Whenever possible, material from hospital charts and therapynotes was used. None of the patients expressed regrets about having surgery,and all showed "a significant improvement in psychological functioning." Aglobal measure of improvement was derived based on responses to interviewmaterial and psychometric testing. The minimal presurgery screening in theoriginal program made it necessary to base many of the conclusions on post hocanalysis. The relationship between quality of surgical results and goodpsychological functioning was found to be statistically significant among 16patients who changed from male to female (p < .01). Summary The studies of the 1970s and early 1980s challenged the idea that sexreassignment surgery was a cure for transsexualism. While prior findings thatsex reassignment surgery leads to better socioeconomic functioning for somepatients were given additional support, gender dysphoric patients werecharacterized as having severe psychopathology that was unaltered by sexreassignment surgery. As an outgrowth of these studies, it was suggested thatcandidates for sex reassignment surgery receive preoperative and postoperativecounseling and/or psychotherapy. Sturup (52) supported this idea, noting, "Insome of the early cases the reluctance on the part of therapists to adopt anactive therapy [had] been too great." While some of the postsurgery studies attempted to identify predictivevariables for use in patient selection for surgery, no uniform diagnosticcriteria were identified or employed. Despite attempts to address the seriousmethodological problems of the earlier studies, the studies of the 1970s endedon a sour note. The media distortion of the Johns Hopkins results suggestedthat sex reassignment surgery was of little or no benefit - a conclusionunsubstantiated by the data but one that has become the focus of much debate.DISCUSSION Methodological Problems of Follow-Up Studies Most of the 785 postsurgical patients (approximately 596 men and 189 women)who have been studied are self-selected; they have voluntarily enrolled in ahospital- or university-based gender identity clinic. Their intensesurveillance includes an extended psychological and behavioral evaluation thatoften lasts over 1 year. A review of follow-up studies suggests that genderclinics' surgical requirements can be met only by patients who can cope withdelayed gratification and frustration; they may even be somewhat passive andcompliant. However, these patients represent only a small percentage of theestimated 30,000 self-labeled transsexuals, of whom 3,000-10,000 havereportedly received sex reassignment surgery. The vast majority of genderdysphoric patients obtain sex reassignment surgery on a fee-for-service basiswithout benefit of a prolonged diagnostic evaluation. As a group they areprobably more impulsive, impatient, anxious, and demanding of sex reassignmentsurgery than are those who enroll in university-based clinics. Many of thesepatients are probably secondary transsexuals who feel surgery will relievetheir emotional distress. Unless these patients need additional surgery, theywill be generally unavailable for follow-up. The lack of baseline data ontheir presurgical psychological states makes it impossible to evaluate thechanges caused by sex reassignment surgery. More over, neither the surgeonswho perform sex reassignment surgery on demand or their patients seem to beinterested in understanding the psychological roots of transsexualism. In order to apply the results of these follow-up studies to the wider groupof postsurgical transsexuals, we must determine whether those who have beenstudied represent an adequate cross-section of all sex reassignment surgerypatients. If not, this sampling bias is a primary methodological probleminherent in all of the published studies on sex reassignment surgery. Areview of those studies reveals other serious methodological problems,including a lack of universally accepted criteria for diagnosing genderdysphoria and determining suitable candidates for sex reassignment surgery;lack of an adequate control group; considerable variability among programs ingender identity clinics as well as in the quality, training, and experience ofclinical staff; failure to include basic data on patients' race and age;frequent use of nonoperationalized criteria for improvement, such as patients'subjective feelings of happiness; use of college grade level systems forevaluating outcome; failure to provide data on the length of time betweenevaluation, surgery, and follow-up; failure to use uniform diagnostic labels;failure to use standardized clinical instruments to assess patients, evenwithin a single study; limitation of clinical investigation to gross, socialpsychological variables; failure to include in-depth psychological analysis;use of hypothetical post hoc analyses to provide missing presurgical data; anduse of biased evaluators to interpret outcome data. This list is by no meansexhaustive. These methodological difficulties can be addressed by providing all sexreassignment surgery patients with uniform clinical interviewing, questioning,evaluation, and treatment schedules and follow-up questionnaires. To dateonly one follow-up study has attempted to fulfill some of these requirements(53). While there are still no uniform criteria for patient selection for sexreassignment surgery, the Harry Benjamin International Gender DysphoriaAssociation has formulated some elementary standards of care for transsexuals(16). This work needs further elaboration before it can become a model.Researchers can begin to overcome the difficulty of small samples by combiningdata from several clinics. This practice would obviously necessitate the useof standardized clinical instruments, clinicians with similar training backgrounds, and uniform criteria for evaluation and treatment. The crucialproblem, however, is the availability of patients for follow-up. Overview of Findings: Two Decades of Research A review of the studies on sex reassignment surgery reveals a diversity offactors used to investigate postsurgical patients (appendix 1). Resultsdiffer depending on which factors are focused on. For example, thoseclinicians who used global ratings found a positive change rate of 68%-86% inthe patients' overall social-emotional functioning. On the other hand, thosewho used more discriminative evaluation criteria (focusing on psychologicalvariables) not only failed to replicate these success rates but occasionallyreported negative outcome in the socioeconomic area of postsurgicalfunctioning. All of these findings must be viewed in light of the variousmethodological weaknesses of the studies reported earlier. Appendix 2 summarizes the positive and negative findings of the studies ofsex reassignment surgery for over two decades of research. Although severalcategories of change have remained constant, the more recent studies havefocused on negative psychological functioning after surgery. These findingsmay be directly related to the increased number of surgical proceduresperformed. However, previous researchers had also sorely neglected themeasurement of psychological functioning after surgery. Perhaps the earlypostsurgery studies failed to report on psychological dysfunction because theevaluators, who were physicians and surgeons, lacked clinical psychiatricexpertise. Indeed, many of them believed that sex reassignment surgery wouldcompletely change the patient's personality structure for the better - therebyabrogating previous psychological disturbances. While no single study hasintensively evaluated the global psychological status of postsurgery patients,the recent focus on psychological variables and especially psychotherapy (54-56) represents an important direction for research. An analysis of those postsurgery studies which focused on the patient'spsychological functioning revealed considerable discrepancy. This waspartially related to the definition of "psychological functioning." The term(which has been used to describe anything from the frequency of psychiatricvisits to responses to personality tests and data from psychotherapy) needs tobe refined in terms of acceptable clinical criteria. Moreover, the status ofpatients' self-reports about their subjective satisfaction or happiness withthat procedure needs to be reconsidered as the sine qua non of outcome. In a preliminary way the studies of the 1970s challenged the notion thatsex reassignment surgery led to complete psychological integration of thepatient's new gender role and identity. While sex reassignment surgery mayhave provided the transsexual with artificial genitals, it did not provide thepatient with the developmental history of a man or woman necessary for being amale or female, e.g., for the man, unique identifications with the mother,typical female preoedipal and oedipal development, experience of participationin a girls' social group, menses, and continued social-psychological reactionsto female development. While psychotherapy can be of considerable benefit forthe gender dysphoric patient, it cannot provide the internal structures ofmaleness or femaleness necessary for internalizing cross-genderidentification. These identifications are primary structures establishedduring early childhood and are not to be gained through sex reassignmentsurgery or psychotherapy. One must not confuse cross-gender social roleadaptation with one's internalization of gender identifications. What, then, does happen after surgery with the gender dysphoric patient?In determining the success of sex reassignment surgery, should one use onlythe results of medical-surgical procedures (i.e., whether the new genitaliaappear realistic and are functional)? Or ought one to be concerned about thepatient's psychological status? While sex reassignment surgery is an invasiveand irreversible procedure, presumed by some investigators to have a negativepsychological effect on the patient, many questions are still unanswered bythe research. Do postsurgery patients exhibit more or less depression,anxiety, or guilt? Are postsurgery patients more or less suicidal orpsychotic? What are the psychological sequelae of male castration and penileamputation and female mastectomies and hysterectomies? While these clinicalquestions have not been fully answered by researchers, they certainly need tobe addressed. While most studies focus on variables that they have related tosuccessful outcome, e.g., social, vocational, economic, and familialvariables, future researchers need to refine their questions. In spite of theapparent objectivity of these social variables, they are no less dependent onone's framework of values than more complex psychological variables. Forexample, is a shy, with drawn, schizoid low-paid clerk who undergoes sexreassignment surgery and becomes an outgoing, highly successful femaleimpersonator or prostitute (earning a high income and having a wide variety ofsocial relationships) considered a success or failure? What are the criteriaused to determine outcome? Bioethical dilemmas such as this need to beaddressed.CONCLUSIONS The reported 68%-86% success rates for sex reassignment surgery must beviewed cautiously. The lack of long-term follow-up studies makes thesestatistics misleading. As long as sex reassignment surgery remains a viabletreatment modality, it is reasonable to ask how one determines which patientswill most benefit from sex reassignment surgery. Currently the selectioncriteria available are informally culled from clinical guidelines establishedby the various gender identity clinics nationwide. These criteria might beused in establishing universally acceptable guidelines for referring a patientfor sex reassignment surgery. In order for these guidelines to be effectiveone would have to ensure that sex reassignment surgery was done only byskilled surgeons in highly selected university-based clinics that couldprovide follow-up. Essentially, this would mean limiting all sex reassignmentsurgery to a select number of hospitals in the United States. While thisraises certain ethical issues, it is clear that current abuse comes from thewidespread availability of sex reassignment surgery and not the other wayaround. While sex reassignment surgery has definite medical-surgical andpsychological limitations, there is insufficient evidence to warrant itstermination. In deed, there is evidence suggesting that some gender dysphoricpatients benefit primarily from sex reassignment surgery (reference 12 and anunpublished study by S. Satterfield). The problem is how to identify thesepatients. The growing body of literature implicating a neurohormonalhypothesis in gender dysphoria (57) also cannot be used to justify sexreassignment surgery, since the disorders of gender dysphoria are primarilypsychological disorders, and it is rare to substantiate a neurohormonaldisorder for any given case. Most gender dysphoric patients, however, aresecondary transsexuals (58) who can benefit from various modes ofpsychotherapy (54-56). To date the evidence suggests that many patients whowould have otherwise undergone sex reassignment surgery may adjust to anonsurgical solution through psychotherapy (7). Moreover, many misdiagnosedgender dysphoric patients need psychotherapy, not surgery (59). Indeed, sexreassignment surgery should only be considered as the last resort for a highlyselect group of diagnosed gender dysphoric patients. It is imperative thatlegislators who wish to provide Medicaid payments for transsexual surgeryunderstand that, in most cases, alternatives to sex reassignment surgery areavailable to patients. Physicians wishing to refer a patient for evaluationfor sex reassignment surgery should be allowed to make use of the manyspecialized gender dysphoria clinics that are currently in operation. As clinicians learn new ways to diagnose and treat transsexualism, eithersex reassignment surgery will be abandoned as a routine treatment modality(reserved for only a few select patients) or new predictive variables forchoosing suitable patients for sex reassignment surgery will be established.Future research needs to focus on long-term follow-up studies maximizing theuse of those methodological issues outlined in this paper which will enhanceour understanding of the etiology and the course of gender identity disorders.REFERENCES Benjamin H: The Transsexual Phenomenon. New York, Julian Press,1966 Randell JB: Preoperative and postoperative status of male andfemale transsexuals, in Transsexualism and Sex Reassignment Surgery. Edited byGreen R. Money J. Baltimore, Johns Hopkins University Press, 1969 Walinder J, Thuwe I: A Social Psychiatric Follow-up Study of 24 SexReassigned Transsexuals. Copenhagen, Scandinavian University Books, 1974 American Medical Association: Human Sexuality. Chicago, AMA, 1972 Brady J, Brodie H (eds): Controversy in Psychiatry. Philadelphia,WB Saunders Co, 1978 Green R: Attitudes toward transsexualism and sex reassignment, inTranssexualism and Sex Reassignment Surgery. Edited by Green R, Money J.Baltimore, Johns Hopkins University Press, 1969 Lothstein L: Psychotherapy with patients with gender dysphoricsyndromes. Bull Menninger Clin 41:563-582, 1977 Barlow D, Abel G, Blanchart E: Gender identity change intranssexuals. Arch Gen Psychiatry 36:1001-1007, 1979 Lothstein L, Levine S: Expressive psychotherapy with genderdysphoric patients. Arch Gen Psychiatry 38:924-929, 1981 Hertz J, Tillinger KG, Westman A: Transvestism: report on fivehormonally and surgically treated cases. Acta Psychiatr Scand 37:283-294, 1961 Meyer J, Reter C: Sex reassignment: follow-up. Arch Gen Psychiatry36:1010-1015, 1979 Hunt DD, Hampson JL: Follow-up of 17 biologic male transsexualsafter sex-reassignment surgery. Am J Psychiatry 137:432-438, 1980 Jorgenson C A Personal Autobiography. New York, Paul E Ericson,1967 Hamburger C: Desire for change of sex as shown by personal lettersfrom 465 men and women. Acta Endocrinol (Copenh) 14:361-375, 1953 Volkin V: Transsexualism: as examined from the viewpoint ofinternalized object relations, in On Sexuality: Psychoanalytic Observations.Edited by Karasu TB, Socarides C. New York, International Universities Press,1979 Berger J, Green R, Laub D, et al: Standards of Care: The Hormonaland Surgical Sex Reassignment of Gender Dysphoric Persons. Galveston,University of Texas Medical Branch, Janus Information Center, 1977 Prince V: Understanding Cross-Dressing. Los Angeles, ChevelierPublications, 1976 Bullough VL: Transsexualism in history. Arch Sex Behav 4:561-571,1975 DeSavitsch E: Homosexuality: Transvestism and Change of Sex.London, William Heinemann Medical Books, 1958 Forgey D: The institution of bedarche among the North AmericanPlains Indians. Journal of Sex Research 11:1-15,1975 21, Warnes H, Hill G: Gender identity and the wish to be a womanPsychosomatics 15:25-29, 1974 Green R: Transsexualism: mythological, historical, and crosscultural aspects, in The Transsexual Phenomenon. Edited by Benjamin H. NewYork, Warner Books, 1977 Money J, DePriest M: Three cases of genital self-surgery and theirrelationship to transsexualism. Journal of Sex Research 12:283-294, 1976 Abraham F: Genitalumwandlung an zwei maenlichen transvestiten.Zeitschrift fur Sexualwissenschaft 18:223-226, 1931 Hoyer N: Man into Woman. New York, EP Dutton & Co, 1933 Money J, Brennan J: Sexual dimorphism in the psychology of femaletranssexuals. J Nerv Ment Dis 147:487-499, 1968 Stoller R: Sex and Gender. New York, Science House, 1968 28, Pauly I: The current status of the change of sex operation. J Nerv MentDis 147:460-471, 1968 Golosow N, Weitzman EL: Psychosexual and ego regression in the maletranssexual. J Nerv Ment Dis 149:328-336, 1969 Money J, Primrose C: Sexual dimorphism with psychology of maletranssexuals. J Nerv Ment Dis 147:472 185, 1968 Newman L, Stoller R: The oedipal situation in male transsexualism.Br J Med Psychol 44:295-303, 1971 Kubie L, Mackie J: Critical issues raised by operations for gendertransmutation. J Nerv Ment Dis 147:131143, 1968 Money J, Ehrhardt A: Transsexuelle nach geschlechtswechsel. BeitrSexualforsch 47:70-82, 1970 Hoenig J, Kenna J, Youd A: Surgical treatment for transsexualism.Acta Psychiatr Scand 47:106 133, 1971 Money J, Wolff G: Sex reassignment: male-to-female-to-male. ArchSex Behav 2:245-250, 1973 Eber M: Gender identity conflicts in male transsexualism. BullMenninger Clin 1:31-38, 1980 Childs A: Acute symbiotic psychosis in a postoperative transsexual.Arch Sex Behav 6:37-44. 1977 Van Putten, Fawzy I: Sex conversion surgery in a man with severegender dysphoria. Arch Gen Psychiatry 33:751-753, 1976 Arieff A: Five year studies of transsexuals: psychiatric,psychological and surgical aspects, in Proceedings of the SecondInterdisciplinary Symposium on Gender Dysphoria Syndromes. Edited by Laub D,Gandy P. Stanford, University of California Press, 1973 Gandy P: Follow-up on 74 gender dysphoria patients treated atStanford. Ibid Ihlenfeld C: Outcome of hormonal-surgical intervention un thetranssexual condition. Ibid Hastings DW, Blum JA: A transsexual research project at theUniversity of Minnesota Medical School. Lancet 87:262-264, 1967 Laub DR, Fisk N: A rehabilitation program for gender dysphoriasyndrome by surgical sex change. Plast Reconstr Surg 53:388-403, 1974 Fisk N: Eight spectacular results, in Proceedings of the SecondInterdisciplinary Symposium on Gender Dysphoria Syndromes. Edited by Laub D,Gandy P. Stanford, University of California Press, 1973 Fisk N: Five spectacular results. Arch Sex Behav 7:351-369, 1978 Gittleson N, Levine S: Subjective ideas of sexual change in maleschizophrenics. Br J Psychiatry 112:779-782, 1966 Gottleib A: Three atypical results. Arch Sex Behav 7:371-375, 1978 Biber S: Surgical experience and follow-up of 100 transsexualcases, in Proceedings of the Fifth Interdisciplinary Symposium on GenderDysphoria Syndromes. Norfolk. Va, University of Eastern Virginia, MedicalSchool, 1977 Hore B, Nicolle F, Calnan J: Male transsexualism in England:sixteen cases with surgical intervention. Arch Sex Behav 4:81-95, 1975 Money J: Ablatio penis: normal male infant sex-reassigned as agirl. Arch Sex Behav 4:65-71,1975 McKee EA: Transsexualism: a selective review. South Med J 69:185-187, 1976 Sturup GK: Male transsexuals: a long-term follow-up after sexreassignment operations. Acta Psychiatr Scand 53:51-63, 1976 Lothstein L: The postsurgical transsexual: empirical andtheoretical considerations. Arch Sex Behav 9:547-564, 1980 Kirkpatrick M, Friedmann CTH: Treatment of requests for sex-changesurgery with psychotherapy. Am J Psychiatry 133:1194-1196, 1976 Lothstein LM: Psychotherapy with patients with gender dysphoriasyndromes. Bull Menninger Clin 41:S63 582, 1977 Morgan A: Psychotherapy for transsexual candidates screened out ofsurgery. Arch Sex Behav 7:273-283,1978 Stoller R: A contribution to the study of gender identity: followup. Int J Psychoanal 60:433-441,1979 Person E, Ovessey L: The transsexual syndrome in males, 11:secondary transsexualism. Am J Psychother 28:174-193, 1974 Newman LE, Stoller RJ: Nontranssexual men who seek sexreassignment. Am J Psychiatry 131:437-441 1974 APPENDIX 1. Factors Investigated by Various Studies of the Results of SexReassignment Surgery Medical Surgical Patients' evaluation Physicians' independent assessment Psychological Psychometric scales Psychiatric interview Number of psychiatric contacts Number of psychiatric hospital admissions Suicide attempts Evidence of psychiatric symptoms Environmental Vocational and economic status Living conditions Income, amount and source Criminality Ability to pass in the new role successfully Use of drugs and alcohol Family and marriage Capacity for a lasting relation with partner Parental support Sexual adjustment Patients' subjective feelings about the surgical result Patients subjective feelings of happiness Overall assessment of result-global ratings Social rehabilitation Social-psychological Social-economic-psychological Social-biological APPENDIX 2. Summary of Positive and Negative Factors of Studies of theResults of Sex Reassignment Surgery Over Two Decades 1960s Positive factors Acceptability as a man or woman Subjective satisfaction with surgery Social Adaptation Lessened conflict with the environment Improved family relations Increased capacity to work, new and better job status Social adaptation Physicians' assessment of surgical results Psychological changes Decreased levels of anxiety Decreased level of depression Negative factors No maternal response Failure to develop an inner schema of femaleness Suicidal threats, gestures, and behaviors Psychiatric disturbances, including drug addiction and depression Role re-reversal, requests for re-reassignment Homosexual prostitution 1970s Positive factors Subjective satisfaction with sex reassignment surgery Increased sexual satisfaction Remission of certain forms of schizophrenia Increased vocational-economic adjustment Improved psychological status correlated with good surgical results Patient's subjective feelings of happiness Lessened conflict with the environment Decrease in acute symptoms Negative factors Requests for more surgery Increased psychiatric illness (73% in one study) No change in psychological status Poor cosmetic appearance Requests for reversal of surgery Massive lawsuits Medical problems (e.g., one patient left decorticate, anotherhaving a leucotomy) Patient left in "freak status," cannot pass in new role or adopts alesbian status after male-to-female sex reassignment surgery Suicidal threats, gestures, and behaviors _uacct = "UA-1102427-5";urchinTracker();_qacct="p-59rSbAjOfV1SU";quantserve(); |
|
