Sex reassignment surgery is perhaps the most controversial issue in psychiatry today. Clinicians involved in the treatment of transsexualism have been accused of "playing God" or colluding with the patient's psychopathology. This paper reviews the literature and argues for a systematic approach to the treatment of transsexualism.
The first medical documentation of transsexualism was made by Friedreich in 1830, although the condition was not considered worthy of investigation until many years later (Althorf et al, 1983). Abraham carried out the first sex reassignment surgery (SRS) in the 1920s, and a subsequent operation was done in 1952 by Paul Fogh-Anderson, a plastic surgeon in Copenhagen, having ascertained that his patient was not psychotic with bodily delusions. The patient, an American ex-army sergeant who later became famous as Christine Jorgensen, was pleased with the results of the surgery and adapted successfully to the feminine role. Less publicized surgical intervention for transsexuals was carried out in Europe in the 1950s and in North Africa, in particular in Casablanca.
Cauldwell (1949) first used the term transsexualism and Fisk (1973) later introduced the term gender dysphoria to describe a sense of uneasiness about one's own gender identity accompanied by depression or anxiety and sometimes by a wish or an attempt to assume the gender role of the opposite sex. The estimated prevalence in Sweden is 1 in 37 000 males and 1 in 103 000 females, and in England and Wales it is estimated as 1 in 34,000 males and 1 in 108,000 females (Walinder, 1968; Hoenig and Kenna, 1974). Transsexualism, which is distinct from homosexuality and fetishistic crossdressing, is a problem of gender identity. The patient is convinced that his/her own psychological gender is the opposite of his/her anatomical sex - in other words there is an anatomical-gender discontinuity (Gagnon, 1977, cited in Roberto, 1983). The term transsexual may therefore be used for persons of either sex who display the following characteristics -
- A sense of belonging to the opposite sex and of having been born into the wrong sex.
- A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant.
- A strong desire to resemble physically the opposite sex and to seek treatment, including surgery, towards this.
- A wish to be accepted in the community as belonging to the opposite sex.
- Persistence of these feelings and convictions, often since childhood
- No evidence of biological or associated psychiatric illness, such as schizophrenia.
The transsexual feels that he/she is trapped in the wrong body. Male transsexuals feel feminine from childhood and often believe they were "girls". This belief is typical of these patients, and it is consistent with their distaste of their own genitalia which are described as "not mine", "not wanted" and "useless". A lack of interest for the penis as an insignia of maleness and a source of erotic pleasure is accompanied by the wish to be rid of it and to be given a woman's body. The same applies to the female transsexual who demands removal of the breasts and of the womb. These patients remember puberty as a painful confusing period, during which erections and emissions for the male, and breast development and menstruation for the female shattered the illusion that they were to grow up in the preferred body. Crossdressing begins in early life, usually on the patient's own initiative and without associated sexual gratification. Crossdressing produces a sense of wellbeing which cannot be obtained by any other means. Passing successfully in the opposite gender role reinforces the belief of being trapped in the wrong body and makes imperative the request for hormonal and surgical treatment. Some transsexuals have a very limited or absent sexual life. The male transsexual prefers masculine "straight" men. These sexual relationships are explained as "heterosexual" because the patient believes that he is female and he is naturally attracted to men. Heterosexual activity is accompanied by the fantasy of being a woman made love to by a man.
This fantasy is necessary in order to achieve arousal and orgasm.
Transsexualism, transvestism, and homosexuality
In clinical practice transsexuals should be differentiated from fetishistic transvestites and effeminate homosexuals, who often present with gender dysphoria and crossdressing behaviour and who can request treatment. The fetishistic transvestite differs from the transsexual in that he considers himself a man and he is usually successful in the male role. Crossdressing behaviour is accompanied by sexual excitement, generally masturbation and orgasm. For the transvestite, the penis as a source of erotic pleasure is an essential element in his rituals, which he does not want to lose. Most transvestites are primarily heterosexual men who prefer women to men both in reality and in their sexual fantasies. It must, however, be acknowledged that transvestites may go through phases in which the pleasure and relief of anxiety obtained by crossdressing are reduced. The fetishistic excitement is substituted by a sense of feeling like a woman, which can take a compulsive character. They may then wish to remain full-time in the female role, and eventually seek treatment, e.g. hormones and occasionally surgery, to be made into a "complete woman". This wish usually occurs at a time of crisis, when switching to the opposite gender role seems to provide a defense against helplessness and depression. In effeminate homosexuals, transsexual fantasies are common, especially in those with a strong feminine identification. Despite the pleasure they derive from acting out their aggressive identifications by caricaturing women, their sense of identity as homosexual men is far stronger than their sense of being female. They are aware of their preference for men and their fascination for the penis as a source of pleasure for themselves and their partners. Only a few effeminate homosexuals request SRS, usually as a result of a crisis in their relationships and a serious loss of confidence in their being attractive and sexually desirable. They may go as far as requesting hormones to develop breasts, but stop short of requesting surgical reassignment of their genitalia.
It has been suggested that transvestites and effeminate homosexuals who express transsexual fantasies and wish for bodily modification should be classified as secondary transsexuals. In primary transsexuals the transsexual impulse stems from childhood and is persistent throughout life (Person and Ovesey, 1974a,b). In secondary transsexuals it tends to appear later and the patient may go through phases of clear active transvestism or effeminate homosexuality before converting to transsexualism. It is, therefore, relevant to be able to recognize a transsexual crisis and to avoid an early simplified diagnosis of transsexualism. Clinical experience suggests that a psychotherapeutic intervention can help the patient to contain the under lying acute anxiety and to return to his usual way of living. Recent studies confirm that secondary transsexuals may adjust better to life when surgery is refused than when it is granted (Lundstrom et al, 1984).
Outcome of SRS
SRS has evoked controversy and has been viewed as both a panacea and a collusion with the patient's psychopathology. The results of SRS have been described in a number of clinical follow-up reports. Pauly (1968) concluded that a group of male transsexuals who underwent SRS were 10 times more likely to have a satisfactory outcome in terms of emotional and social adjustment than a group who did not. Randell (1969) reported that of 29 male transsexuals who underwent SRS, two thirds showed marked improvement in social and psychological adjustment. Only two showed a worsening of the condition and both of these were psychopathic. Laub and Fisk (1974), in a 6-year follow-up of postoperative transsexuals found that the most significant factor which led to a satisfactory outcome was a successful preoperative adjustment in the gender role of choice during a 1-3 year trial period. Walinder and Thuwe (1974) concluded that the outcome of surgery was favourable in approximately 80% of cases. They further argued: "…when we consider the suffering and many difficulties experienced by untreated transsexuals in many fields of life, the treatment programme appears to be fully justified, both medically and ethically." Walinder et al (1978) suggested that psychosis, unstable personality, inadequacy in self-support, mental retardation, alcoholism, drug abuse and criminality are all negative prognostic factors and that active intervention should be discouraged if they are present. Lothstein (1984) in his critical review of psychological studies reported that there was evidence of severe psychopathology in male transsexuals at the preoperative stage, and that at postoperative assessment transsexuals were shown to have a higher level of psychological adjustment. Lundstrom et al (1984), in a comprehensive review of postoperative follow-up studies, suggested that the majority of findings showed an improvement of psychological functioning and general psychopathology following SRS. They noted that 10-15% of SRS ended in failure. They argued that primary transsexuals have a better postoperative outcome than secondary transsexuals, and that for secondary transsexuals the outcome is equal or better when surgery is refused. Blanchard et al (1985) reported improvement in psychological functioning following SRS in selected cases of male transsexuals. A more recent study by Mate-Kole et al (1987) suggested that SRS reduced psychiatric morbidity in a group of 50 male transsexuals when compared with a group of patients on a waiting list for surgery and a group undergoing assessment.
Against this body of favourable evidence there are a number of studies which express reservations. Hoenig et al (1971) argued that SRS helped a majority of patients both subjectively and objectively but the operation could in no sense be regarded as a cure. Newman and Stoller (1971) reported that although surgery produces a change in a person's secondary sexual characteristics, inner male and female identity remains untouched. Sturup (1976) found that all his patients had psychological problems, including family rejection, difficulty at work, sexual adjustment, depressive ideation, suicidal behaviour and reactive psychosis. Nevertheless, all the patients were satisfied with the surgical outcome. A more recent study by Beatrice (1985) assessed the psychological functioning of four groups each of 10 subjects (heterosexual males, transvestites, preoperative male transsexuals and postoperative male transsexuals) using the Minnesota Multiphasic Personality Inventory and the Tennessee Self-Concept Scale. He reported that both preoperative and postoperative patients showed evidence of psychotic functioning which surgery did not relieve.
Criteria for SRS
Once a diagnosis of transsexualism has been made, recommendation for SRS should be based on strict criteria as laid down by The Harry Benjamin International Gender Dysphoria Association (1985) as follows:
- The patient should show evidence of stable transsexual orientation.
- The patient should show insight into his/her condition and should not suffer from any serious psychiatric disorder.
- The patient should be able to pass successfully as a member of the opposite sex, and there should be clear evidence of cross-gender functioning.
- Improvement in personal and social functioning should be predicted for the individual prior to and after surgery.
Evidence from the majority of studies to date suggests that SRS is followed by an improvement in psychological status. Lundstrom et al (1984) in a general review of the literature reported as follows:
- Satisfactory outcome to some degree is dependent upon good cosmetic outcome and functional results of surgery, but other variables can affect the patient's perception of overall satisfaction.
- Personal and social instability are correlated with unsatisfactory results and this is an indication that the transsexual should be supported both preoperatively and postoperatively if SRS is to be considered.
- There is an inverse relationship between increasing age at the time of request for surgery and favourable outcome.
- Not only do secondary transsexuals have a higher frequency of unsatisfactory outcome, but it is indicated that when such patients are refused surgery they manage their lives reasonably well and tend to give up their pursuit of SRS.
SRS is the treatment of choice for carefully selected genuine primary transsexuals only. Caution should be paid to patients with unstable backgrounds and diagnostic criteria should be consistent. There is no doubt that transsexualism is an extreme form of gender dysphoria. However, whether SRS is the treatment of choice is equivocal. Therefore, future studies should adopt a multidisciplinary approach ranging from psychiatric and neuropsychological evaluation to sociological and physiological investigations to improve the definition of indications and predictors for SRS.
We are deeply indebted to Dr Ashley Robin, Honorary Consulting Psychiatrist, Charing Cross Hospital, for reading this paper and for his invaluable comments.
© Mate-Kole C, Freschi M., Department of Psychiatry, Charing Cross and Westminster Hospitals Medical School, London, British Journal of Hospital Medicine. 1988 Feb;39(2):153-5.
- Althorf, S, Lothstein M, Jones, P, Shen, J (1983) An MMPI subscale (Gd): to identify males with gender identity conflicts. Journal of Personality Assessment, 47, 1, 42-49.
- Beatrice, J (1985) A psychological comparison of heterosexuals, transvestites, preoperative transsexuals and post-operative transsexuals. Journal of Nervous and Mental Disease, 173, 358-365.
- Blanchard, R, Steiner, B, Clemmensen, H (1985) Gender dysphoria, gender re orientation, and the clinical management of transsexualism. Journal of Consulting and Clinical Psychology, 53, 293-304.
- Cauldwell, D (1949) Psychopathia transsexualis. Sexology, 16, 274-280 Fisk, N (1973) Gender dysphoria syndrome (the how, what and why of a disease). In Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome (edited by Laub, D, Gandy, P). University of California Press, Palo Alto. pp.7-14.
- Hoenig, J, Kenna, J (1974) The prevalence of transsexualism in England and Wales. British Journal of Psychiatry, 124, 181-190.
- Hoenig, J, Kenna, J, Youd, A (1971) Surgical treatment of transsexualism. Acta Psychiatrica Scandinavica, 47, 106-136.
- Laub, D, Fisk, N (1974) A rehabilitation programme for gender dysphoria syndrome. Plastic and Reconstructive Surgery, 53, 388-403.
- Lothstein L, (1984) Psychological testing with transsexuals: a 30 year review. Journal of Personality Assessment, 48, 5, 500-507.
- Lundstrom, B, Pauly, I, Walinder, J (1984) Outcome of sex reassignment surgery. Acta Psychiatrica Scandinavica, 70, 289-294.
- Mate-Kole, C, Freschi, M, Robin, A (1987) Aspects of psychiatric symptomatology in the treatment of transsexualism. British Journal of Psychiatry, in press.
- Newman, L, Stoller, R (1971) The Oedipal situations in male transsexualism. British Journal of Medical Psychology, 44, 296-303.
- Pauly, I (1968) The current status of the change of sex operations. Journal of Nervous and Mental Disease, 147, 460-471.
- Person, E, Ovesey, L (1974a) The transsexual syndrome in males: 1. Primary transsexualism. American Journal of Psychotherapy, 28, 4-20.
- Person, E, Ovesey, L (1974b) The transsexual syndrome in males: 11. Secondary transsexualism. American Journal of Psychotherapy, 28, 174-193.
- Randell, J (1969) Pre-operative and post-operative status of male to female transsexuals. In Transsexualism and Sex Reassignment (edited by Green, R, Money, J). Johns Hopkins University Press. pp.355-382.
- Roberto, L (1983) Issues in diagnosis and treatment of transsexualism. Archives of Sexual Behavior, 12, 5, 445-473.
- Sturup, G (1976) Male transsexuals: a long term follow-up after sex reassignment operations. Acta Psychiatrica Scandinavica, 53, 51-63.
- The Harry Benjamin International Gender Dysphoria Association (1985) Standards of care: the hormonal and surgical sex reassignment of gender dysphoric persons. Archives of Sexual Behavior, 14, 1, 79-90.
- Walinder, J (1968) Acta Psychiatrica et Neurologica Scandinavica, Suppl., 203, Walinder, J, Thuwe, I (1974) A Social Psychiatric Follow-up Study of 24 Sex Reassigned Transsexuals. Scandinavian University Books, Copenhagen.
- Walinder, J, Lundstrom, B, Thuwe, I (1978) Prognostic factors in the assessment of male transsexuals for sex reassignment. British Journal of Psychiatry, 132, 16-20.
- Baker, H, Green, R (1970) Treatment of transsexualism. Current Psychiatric Therapies, 10, 88-89.
- Benjamin, H (1966) The Transsexual Phenomenon. Julian Press, New York Benjamin, H (1967) Transvestism and transsexualism in the male and female. Journal of Sexual Research, 3, 107-127.
- Blanchard, R, Clemmensen, L, Steiner, B (1983) Gender re-orientation and psychosocial adjustment in male to female transsexuals. Archives of Sexual Behaviour, 12, 6, 503-509.
- Edgerton, M (1984) The role of surgery in the treatment of transsexualism. Annals of Plastic Surgery, 13, 6, 483-481.
- Green, R, Money, J (1969) Transsexualism and Sex Reassignment. Johns Hopkins University Press, Baltimore.
- Hunt, D, Hampson, J (1980) Follow-up of 17 biological male transsexuals after sex reassignment surgery. American Journal of Psychiatry, 137, 432-438.
- Laub, D, Gandy, P (Eds) (1973) Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndromes. University of California Press, Palo Alto.
- Lothstein, L (1982) Sex reassignment surgery: historical, bioethical, and theoretical issues. American Journal of Psychiatry, 139, 4, 417-426.
- Money, J, Primrose, C (1968) Sexual dimorphism with psychology of male transsexuals. Journal of Nervous and Mental Disease, 147, 472-485.
- Randell, J (1970) Transvestism and transsexualism British Journal of Hospital Medicine, 3, 211-213.
- Schapira, K, Davison, K, Brierley, H (1979) The assessment and management of transsexual problems. British Journal of Hospital Medicine, 22, 63-67.