Fighting for acceptability... transsexualism

Nursing Standard. 10(46): 22-3, 1996 Aug 7.

Fran Springfield is a passionate believer in the rights of transsexuals. She talked to Charlotte Alderman about her work and the discrimination still faced by this client group.

Further insights into transsexualism

Psychopathology. 29(1); 1-6; 1996.
Becker D, Mester R.

Transsexualism is a challenging entity posing diagnostical, etiological, ethical and moral questions with no general consensus of opinion and a controversial management policy. The present article tries to deal with these questions by drawing a parallel with another psychiatric syndrome in which there is also a disturbance in body image, namely anorexia nervosa. The parallel is at the level of clinical presentation, psychodynamic etiology and their common socioepidemic dimension. (17 ref)

Gender dysphoria update

Journal of Psychosocial Nursing & Mental Health Services. 34(4):12-9, 35-6, 1996 Apr.
Beemer BR.

Concepts of sexuality and gender identity are undergoing re-examination in society. Recent media attention has intensified interest in the area, although reliable information is sometimes lacking. Gender dysphoria, and its extreme form, transsexualism, frequently brings sufferers into contact with psychiatric, social, and mental health professionals, and surgical caregivers. Treatment of these patients often represents a challenge on many levels. Some guidelines for this care are outlined. (14 ref)

Transsexualism - general outcome and prognostic factors: a five-year follow-up study of ninteen transsexuals in the process of changing sex

Archives of Sexual Behaviour. 25(3); 303-315; Jun 1996.
Bodlund O, Kullgren G.

Nineteen transsexuals, approved for sex reassignment, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behaviour), and DMT (Defence Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n=13) had improved in at least two areas of functioning. In 3 cases (16%) outcome was judged as unsatisfctory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

Psychiatric aspects of transsexualism [In French]

Bulletin de l'Academie Nationale de Medecine. 180(6); 1389-1394; Jun-Jul 1996.
Breton J, Cordier B.

Transsexualism is a mental disease in which gender identity goes contrary to corporal reality. Diagnosis is purely clinical and needs a prolonged observation. The actual experience concerning about 700 cases allow us to consider that one quarter should get sexual conversion.

Transsexualism, sex and gender

International Forum of Psychoanalysis. 6(2); 141-146; Jul 1997.
Ceccarelli P.

How does the body into which a baby is born become a sexual body? Do the anatomical characteristics of masculine or feminine constitute a guarantee for a subject to say that he/she is a man or a woman? The passage from identifications to identity is a most complex one. To try to clarify this process the author starts by making some reflections on the notion of identity itself from the psychoanalytical point of view. This leads to a central question which is to know if one is born a boy or a girl, or if one becomes one. Working with the fundamental concept of primary identification and the distinction of sex and gender, the author shows, through a clinical vignette, that anatomy is no assurance for a construction of a feeling of gender identity according to anatomical sex.

Auditory cerebral lateralization following cross-gender hormone therapy

Cortex. 31(3):565-73, 1995 Sep.
Cohen H, Forget H.

In this study, 10 men, 10 women, and 13 genetic male transsexuals, all of them right-handed, were tested on two verbal (CV and nonsense polysyllables) and two nonverbal (melodies and triple tone [3T]) dichotic tasks to investigate relations between hormone therapy and auditory cerebral specialization for speech and non speech stimuli in adults. At time of testing, all transsexuals had been under hormonal treatment for at least one year and eight had had corrective surgery. ANOVA results showed a right ear advantage and similar pattern of performance for the three groups in the treatment of speech. In nonverbal tasks, interactions revealed a left ear advantage in the processing of melodies and 3T for men only; women and transsexuals exhibited similar performance in both nonverbal tasks. In accord with generalization from the animal literature, cautious interpretation of the data is some possible hormonal involvement, in adults, in the modulation of right hemispheric cognitive processing. (48 ref)

Comorbidity of gender dysphoria and other major psychiatric diagnoses

Archives of Sexual Behaviour. Vol 26(1), Feb 1997, 13-26.
Cole CM, O'Boyle M, Emory LE, Meyer WJ.

Examined retrospectively via an interview and a questionnaire the comorbidity between gender dysphoria (GD) and major psychopathology (PP). The charts of 318 males (mean age 32 years) and 117 females (mean age 30 years) with self-reported GD were evaluated. It was found that over two-thirds were undergoing hormone reassignment, suggesting a committment to the real-life cross-gender process. 28% reported having substance abuse problems before treatment but less than 15% evidenced problems associated with mental illness, genital mutilation, or suicide attempts. A subgroup of 137 Ss who completed the MMPI showed profiles that were notably free of PP. Significant differences were observed only in the Mf scale, and this held true only for the male-female group. Psychological profiles as measured by the MMPI were more 'normal' in the desired sex than the anatomic sex. These support the view that GD is usually an isolated diagnosis and not part of any general PP.

Unveiling the mystique of gender dysphoria syndrome

Nursing Forum. 31(2): 15-22, 1996 Apr-Jun.
Colucciello ML.

There are common myths surrounding the condition of gender dysphoria and individuals seeking therapy. The diagnosis of gender dysphoria syndrome is applied to individuals who feel ill at ease with their biological body and either seek hormonal reassignment therapy or hormonal therapy and sex reassignment surgery. The author discusses standards of care, diagnostic criteria, physiological and psychological changes incurred through hormonal therapy are introduced as well as surgical techniques. By assisting individuals with gender dysphoria syndrome to enhance the integration of their new gender role into their self-identity, nurses are in an excellent position to facilitate improvements in their overall health status as well. (20 ref)

Stages of adjustment in family members of transgender individuals

Journal of Family Psychotherapy. Vol 7(3), 1996, 1-12.
Emerson S, Rosenfeld C.

While the clinical literature contains descriptions of the families and partners of transgender individuals, a description of the family members' processes of adjustment to a relative's transgender identity has not previously appeared in the family therapy literature. Family members experience different processes from the transgender individual. This article discusses stages that family members may experience and is directed towards therapists who work with any member of the family, as well as toward transgender individuals who may need to understand their families' experience.

Endocrine therapy of transsexualism and potential complications of long-term treatment

Archives of Sexual Behaviour. 27; 2; 1998; 209-26.
Futterweit W.

Physiological principles of the interrelationship of sex hormones and their regulation are the foundation of understanding appropriate treatment of the trassexual patient. While both genetic males and females have oestrogens and androgens, the quantative sex hormone production is genetically predetermined by sex hormone production both in the gonads and via peripheral conversion of hormone precursors to sex steroids. Sex hormones exert a negative feedback on the hypothalamus and pituitary gland whereby gonadotropin-releasing hormone (GnRH), pituitary luteinizing (LH) and follicle-stimulating hormone (FSH) are regulated or suppressed by the endogenous levels of these hormones. Sex hormonal therapy induces attentuated GnRH stimulation of LH and FSH causing a reduction of serum sex hormone levels. It is clear that oestrogen as well as androgen therapy have a dual role:

  1. induction of feminisation or virilisation and
  2. suppression of the hypothalamic-pituitary-gonadal axis leading to a reduction of endogenous oestradiol or testosterone secretion.

Cross-sex hormonal therapy may have substantial medical side-effects. The smallest dosage of hormonal therapy compatible with the above clinical aims should be used. (67 refs.)

Hormones and psychosexual differentiation

Minerva Endocrinologica. 20(3); 165-193; Sep 1995.
Giordano G, Giusti M.

The male phenotype arises from the optimal concordance of chromosomal, gonadal and hormonal sex. Hormonal sex depends directly on the type of gonads that have been formed, and is linked both to the production of hormones and to their optimal effect on target tissues. The present review underlines the fact that psychosexual orientation in the male is also related to factors linked to sex hormones. Many of the experimental and clinical data available militate against the long-held belief that the development of role and gender identity in man is predominantly determined by environmental factors. This study points out the importance of hormonal factors at the CNS level. The most common abnormalities of sexual orientation are homosexuality and transsexualism. Despite their relatively high frequency in the general population, research into possible biological influences in these abnormalities is very scant. The authors of the present paper have reviewed the literature data yielded by biological and hormonal studies on homosexuality and transsexualism. These data seem to support the hypothesis that androgens may be deficient in the CNS of male homosexuals. Morphological or functional (neurotransmitter) anomalies in androgen actions at the CNS level could also favour radical dissociation between psychological sex and gonadal, hormonal and phenotypic sex in transsexualism. In conclusion, the present review seems to indicate that hormonal factors (gonadal and adrenal hormones, hormone receptors, transduction mechanism of the hormonal signal, neurosteroids, neurotransmitters etc.) play a determining role in the formation of gender identity. (228 ref).

Gender differences in behaviour: Activating effects of cross-sex hormones

Psychoneuroendocrinology. 20(4); 343-363; 1995.
van Goozen SHM, Cohen-Kettenis PT, Gooren LJG, Frijda NH, et al.

Examined the effects of cross-sex hormone therapy on gender behaviour differences. Tests on aggression, sexual motivation, and cognitive functioning were administered to 35 female-to-male transsexuals and 15 male-to-female transsexuals (all subjects aged 20-45 years) shortly before and 3 months after the start of cross-sex hormone treatment in a Dutch hospital. The administration of androgens to females was clearly associated with an increase in aggression proneness, sexual arousability, and spatial ability, but it had a deteriorating effect on verbal fluency tasks. Upon androgen deprivation in the male-to-female group, anger and aggression proneness, sexual arousability, and visuospatial ability decreased, whereas verbal fluency improved. Results suggest that cross-sex hormones directly and quickly affect gender-specific behaviours.

Transsexualism and the law

Bulletin of the American Academy of Psychiatry & the Law. 22(4): 511-517, 1994.
Green R.

Transsexuals pose dilemmas for the law in terms of defining a male or female; deciding what partners are legally acceptable for marriage; assessing the best interests of children after divorce; interpreting employment discrimination based on gender or handicap; and permitting public cross-dressing. Other dilemmas are reviewing 3rd-party reimbursement for medical procedures that may be deemed cosmetic or experimental; determining elegibility for sports competition; meeting military needs; and determining socially and medically acceptable treatment in prison. Leading law cases are reviewed in each area, with commentary on research findings.

Transsexual surgery follow-up: Status in the 1990's

Annual Review of Sex Research. Vol 1, 1990, 163-174.
Green R, Fleming DT.

Reviews follow-up literature from 1979-2989 on both male-to-female and female-to-male postoperative transsexuals. Preoperative factors indicating a favourable outcome included the following: reasonable degree of mental and emotional stability shown in life history with no psychosis, successful adaptation in the desired role for at least 1 year, with convincing physical appearance and behaviour, sufficient understanding of the limitations and consequences of surgery; and preoperative application of psychotherapy. Surgical adequacy was found to be a major factor in favourable outcome. The lack of reported standardized selection criteria for surgery and the infrequent use of standardized outcome instruments and rating criteria make follow-up conclusions difficult. It is suggested that follow-up measures be improved by incorporating more detailed autobiographical accounts.

Acoustic and perceptual implications of the transsexual voice

Archives of Sexual Behaviour. 24(3); 339-348; Jun 1995.
Guenzburger D.

Conducted two experiments concerning voice characteristics of male-to-female transsexuals. In a speech production experiment (Experiment 1), isolated words and longer utterances of six adult transsexual speakers were realized in a male and female mode. Speech samples were compared intraindividually, and the number of acoustic parameters was analyzed. Subjects appeared to realise vocal charcteristics that added to a feminine voice quality in the female speaking mode. In a perceptual task (Experiment 2), 25 male and 25 female versions of speech samples were presented pairwise to listeners (who did not know subjects were transsexuals). Listeners usually identified the intended speaker sex mode, thus corroborating the acoustic findings. Results suggest that

  • speech therapists should try to enhance feminine voice characteristics to further develop their effectiveness, and
  • speech and voice therapy should be included in rehabilitation of transsexuals.

Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals

Plastic & Reconstructive Surgery. 101(6); 1512-1515; May 1998.
Hage JJ, Karim RB.

When inversion of combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has become impossible or has not led to functional results, alternative vaginoplast techniques should be considered. Colocolpopoiesis involves major surgery and often leads to disappointing long-term results. An Abbe-McIndoe vaginoplasty applying split-thickness skin grafts often does not provide favourable results in the scarred area encountered after complications of skin flap inversion surgery. Because thicker skin grafts show less tendency to shrink, the use of a full-thickness skin graft has been advocated for vaginoplasty in females. In this paper, we present our technique of successful secondary vaginoplasty applying full-thickness skin grafts in six male-to-female transsexuals. In patients with sufficient groin and abdominal skin to spare, a miniabdominoplasty allows for acceptable donor site scarring with correction of the abdominal skin surplus. In flat-tummied patients, the conventional abdominoplasty will allow for sufficient skin to be harvested to ensure successful secondary vaginoplasty. Abdominoplastic vaginoplasty has been proven to provide a good alternative whenever a laparotomy is not favoured or is contraindicated in secondary cases.

Sexual orientation confusion among spouses of transvestites and transsexuals following disclosure of spouse's gender dysphoria

Journal of Psychology & Human Sexuality. 9(2); 39-51; 1997.
Hunt S, Main TL.

Conducted a phenomenological study of 4 women (2 wives of transvestites and 2 wives of transsexuals) to explore the event, if any, of sexual orientation confusion experienced by the nontranssexual spouse. Subjects (aged 35, 48, 36, and 38 years) were asked 40 open-ended questions in an interview with the experimenters. Sexual orientation confusion was operationally defined as the subject questioning her heterosexuality and evidenced by statements found within the text of the interview and identified as such by indepedent readers of the text. The hypothesis that sexual orientation confusion in the wives followed disclosure of the husband's cross-gendered behaviour was confirmed among wives of the transvestites. However, this was not true of the wives of the transsexuals.

Occupational therapy with a male-to-female transsexual: a case study

British Journal of Occupational Therapy. 56(9): 322-4, 1993 Sep.

A transsexuals performance in the chosen gender role can be seen in the context of functional performance of life skills, and should thus potentially be improved with appropriate occupational therapy. A detailed case study is used to illustrate the application of occupational therapy assessment and treatment with one such person, a young male-to-female transsexual in the very early stages of the lengthy pre-surgery assessment phase. (4 ref)

Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility

Annals of Plastic surgery. 37(6); 669-675; Dec 1996.
Karim RB, Hage JJ, Mulder JW.

The surgical aim of genital reassignment surgery in male-to-female transsexuals is to create a perineogenital complex as feminine in appearance and function as possible. In this paper, we present a review of the various methods to line the neovagina in male-to-female transsexuals. These methods may be classified in five categories involving, respectively, application of nongenital skin grafts, penile skin grafts, penile skin flaps, nongenital skin flaps, and pedicled intestinal transplants. Based on this review and our extensive personal experience, we come to certain recommendations regarding the eligibility of these methods. (60 ref)

Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones

Clinical Endocrinology. 48(3); 347-354; Mar 1998.
van Kesteren P, Lips P, Gooren LJ, Asscheman H, Megens J.

OBJECTIVE - It is unknown whether long-term cross-sex hormone treatment affects the human skeleton. We monitored bone mineral density and biochemical markers of bone turnover for 28-63 months in 20 male-to-female transsexuals (M-to-F) treated with anti-androgens and oestrogens, and 19 female-to-male transsexuals (F-to-M) treated with androgens. They underwent gonadectomy 13-35 months after the start of cross-sex hormone administration.
DESIGN - Bone mineral density (BMD) and the markers of bone turnover osteocalcin, alkaline phosphatase, fasting urinary calcium/creatinine and hydroxyproline/creatinine, were measured at baseline, after 1 year and after 28-63 months of cross-sex hormone administration.
RESULTS - In oestrogen-treated M-to-F, variables of bone turnover decreased significantly with consecutive measurements. BMD had increased significantly after 1 year, but decreased again to baseline levels after 28-63 months of cross-sex hormones. In F-to-M, alkaline phosphatase levels increased during the first year. BMD did not change during the first year but had decreased significantly after 28-63 months following ovariectomy. In both M-to-F and F-to-M, the change of BMD correlated inversely with serum LH and FSH levels. Of all biochemical variables LH levels appeared to be the best predictor of loss of BMD; in the long-term LH levels were more elevated in testosterone-treated F-to-M than in oestrogen-treated M-to-F transsexuals.
CONCLUSION - In M-to-F, oestrogen treatment prevented bone loss after testosterone deprivation. In F-to-M the testosterone dosage used, associated with a decline in serum oestradiol levels, was unable to maintain bone mass fully in all subjects in the longer term. The inverse relationship between BMD and serum LH levels suggests that the dose of hormone replacement has been too low in subjects with a decline in their BMD. Its cause might be underdosing or non-compliance in some patients. We propose that serum LH levels may be used as a measure of the adequacy of replacement with sex steroids.

Mortality and morbidity in transsexual subjects treated with cross-sex hormones

Clinical Endocrinology. 47(3); 337-342; Sep 1997.
van Kesteren P, Asscheman H, Megens JA, Gooren LJ.

OBJECTIVE - The optimum steroid hormone treatment regimes for transsexual subjects has not yet been established. We have investigated the mortality and morbidity figures in a large group of transsexual subjects receiving cross-sex hormone treatment.
DESIGN - A retrospective, descriptive study in a university teaching hospital.
SUBJECTS - Eight hundred and sixteen male-to-female (M-to-F) and 293 female-to-male (F-to-M) transsexuals.
INTERVENTIONS - Subjects had been treated with cross-sex hormones for a total of 10,152 patient-years.
OUTCOME MEASURES - Standardised mortality and incidence ratios were calculated from the general Dutch population (age and gender adjusted) and were also compared to side effects of cross-sex hormones in transsexuals reported in the literature.
RESULTS - In both the M-to-F and F-to-M transsexuals, total mortality was not higher than in the general population and, largely, the observed mortality could not be related to hormone treatment. Venous thromboembolism was the major complication in M-to-F transsexuals treated with oral oestrogens and anti-androgens, but fewer cases were observed since the introduction of transdermal oestradiol in the treatment of transsexuals over 40 years of age. No cases of breast carcinoma but one case of prostatic carcinoma were encountered in our population. No serious morbidity was observed which could be related to androgen treatment in the F-to-M transsexuals.
CONCLUSION - Mortality in male-to-female and female-to-male transsexuals is not increased during cross-sex hormone treatment. Transdermal oestradiol administration is recommended in male-to-female transsexuals, particularly in the population over 40 years of age in whom a high incidence of venous thromboembolism was observed with oral oestrogens. It seems that in view of the deep psychological needs of transsexuals to undergo sex reassignment our treatment schedule of cross-sex hormone administration is acceptably safe.

Factors predictive of regret in sex reassignment

Acta Psychiatracta Scandinavica. 97 (4); 248-289; Apr 1998.
Landen N, Walinder J, Hambert G, Lundstrom B.

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.

Prevalence, incidence and sex ratio of transsexualism

Acta Psychiatracta Scandinavica. 93(4); 221-223; Apr 1996.
Landen M, Walinder J, Lundstrom B.

Frequency figures for transsexualism, concerning incidence, prevalence and sex ratio calculated in the 1960's and 1970's, were compared with recent reports. The incidence figures remained constant over time, whereas the prevalence figures tended to increase during the review period. The incidence was found to be of the same magnitude in men and women, while the corresponding ratio for prevalence figures was 3 : 1. It is suggested that men seeking sex reassignment represent a more heterogeneous group than women, and that the reported male predominance to date is due to a lack of categorical studies of primary/genuine transsexualism. It would appear that genuine transsexualism is, on the whole, insensitive to societal changes. The fundamental disturbance underlying this psychosexual disorder is suggested to be neurobiological in origin. (18 ref)

Transsexualism in medicolegal limine: An examination and a proposal for change

Journal of Psychiatry & Law. 24(1); 27-51; Spr 1996.
Loue S.

Considers transsexualism and the creation of a state of medicolegal limine for transsexuals. The article addresses transsexuality as it is currently defined annd explores the dichotomization of sex and gender. The author discusses both the social construction and the praxis of transsexuality, highlighting the medicolegal implications resulting from the current approach to transsexuality. The author argues that the creation of a medicolegal limine essentially prevents transsexuals from ever integrating fully as a member of one sex or gender, while simultaneously preventing the larger society from reconsidering its definitions of sex and gender. The article concludes with a summary of current challenges to the authors' model of transsexualism with suggestions for the resolution of this liminal medicolegal phase.

Acknowledging mixed-sex people

Journal of Sex & Marital Therapy. Vol 22(4), 1996, 265-274.
McKain TL.

This article calls attention to the importance of more carefully defining femaleness and maleness and more fully acknowledging the existence of mixed-sex people. Mixed-sex people are defined as people with at least one female and one male characteristic, where female or male characteristics are defined as characteristics that are possessed by no more than roughly half the population (the distribution criterion) and either play a clear role in reproduction (the reproduction criterion) or are very highly correlated across all cultures with characteristics that meet both the distribution and reproduction criteria (the correlation criterion). Among other recommendations, those who work in the field of human sexuality are urged, on the basis of these more careful definitions and on ethical grounds, to use the term sex-simplification rather than sex-change in describing surgical/hormonal treatments for transsexuals and to radically alter their use of the terms heterosexual and homosexual.

Unlocking the doors... transsexualism, special hospitals

Nursing Times. 91(14): 38-9, 1995 Apr 5-11.
McKeown M, McCusker B.

Nursing a male patient who decides he is really a woman presents particular challenges. When the patient is in a special hospital, there are additional obstacles. Mick McKeown and Brendan McCusker explain. (6 ref)

Transsexuals' narrative construction of the 'true self'

Social Psychology Quarterly. 59; 3; 1996; 176-192.
Mason-Schrock D.

The study of self-narratives thus far has sought to discern the internal structures of the stories people tell to give meaning to themselves. This approach, however, neglects the interactive processes through which self-narratives are constructed. By studying preoperative transsexuals, who are preparing for a radical identity change, one can observe the interactive processes through which stories are used to construct a new self. Based on participant observation in a transgender support group with 10 transsexuals (aged 31-47 years), in-depth interviews, and analysis of written materials, the present study shows how transsexuals collaborated, through modelling, guiding, selective affirming, and tactful blindness, to fashion biographical stories that defined into existence a differently gendered 'true self'. It also shows how dominant gender ideologies provided resources for fashioning plausible self-narratives.

Psychosocial adjustment in male-to-female transsexuals: an overview of the research evidence

Journal of Psychology. 131(6); 602-614, Nov 1997.
Midence K, Hargreaves I.

Transsexualism has been defined as an extreme gender dysphoria; it refers to unhappiness with one's biological sex and the desire to have the body of the opposite sex and to be regarded by others as a member of that other sex. Transsexualism is not a common condition, but its prevalence is not yet known. A large number of transsexuals receive hormonal treatment and sex reassignment surgery (SRS). In spite of years of poor quality research, due in part to methodological problems, recent research on surgical outcomes has provided important information. However, psychological research into transsexualism has ignored the cognitive style and psychological functioning of transsexuals, and very little effort has been made to incorporate research findings into the development of psychological treatments to improve the quality of life for transsexuals. (52 ref)

Men as women: Experiences from five cases after administrative, hormonal, and surgical treatment

Nordic Journal of Psychiatry. 50(5); 395-399; 1996.
Olsson SE, Jansson I, Moeller A.

Describes adjustments of five white biological men as women after administrative, hormonal, and surgical treatment for sex change, with emphasis on the psychologic course, and thereby provide a qualitative aspect to the treatment which traditional followup studies lack. Negative effects of the treatment comprised not only somatic, sexual, and social complications but also psychological difficulties such as indirect regret and suicidal thoughts. In light of the patients' postoperative life situations, sex change treatment appears almost counterproductive, since the definitive surgical treatment they underwent fixated the patients in a defensive position, which prevented the natural maturity and development of their own personality into a "true self".

Situated knowledges of personal embodiment: Transgender activists' and psychological theorists' perspectives on 'sex' and 'gender'

Theory & Psychology. 6(4); 625-645; Nov 1996.
Parlee MB.

Academic psychologists' treatment of 'sex' as an ahistorical, pretheoretical notion in theories of 'gender' is compared and constrasted with knowledge produced by persons whose own gendered embodiment is outside binary gender/sex categories and whose moral agency is erased by theories depicting them as exceptions to a binary-based scheme. This latter knowledge, emerging from an activist community's reflections on ideologies, has selectively incorporated, challenged and transformed gender/sex discourses in significant segments of medicine and academic disciplines other than psychology. Psychological theories continue to reproduce binary categories (and practices organised around them), in part because they incoporate only some of the implications of a social constructivist perspective, and in part because psychologists seem to theorise gender/sex in isolation from other knowledge-producing communities.

Surgical sex reassignment: A comparative study of international centres

Archives of Sexual Behaviour. 24(2); 135-156; Apr 1995.
Petersen ME, Dickey R.

Examined policies and criteria (P&Cs) currently used by European and North American gender identity clinics, using in part the Harry Benjamin International Gender Dysphoria Association's (HBIGDA) Standards of Care that set out minimum standards for the selection of patients for sex reassignment surgery. Of 19 clinics that responded to the survey, only 5 indicated that they adhere to the HBIGDA standards in their entirety. Most clinics had general P&Cs that exceed those of the HBIGDA standards. A relatively high degree of consistency exists between gender clinics in different countries regarding P&Cs for approving surgical sex reassignment for transsexual patients. Where differences occur, they tend to concern not the criteria themselves but rather how satisfaction of the criteria is actually monitored to ensure that patients are genuinely in compliance with the expectations of the treating clinic. The survey is appended.

Children of a transsexual father: A successful intervention

European Child & Adolescent Psychiatry. 4(2); 136-139; Apr 1995.
Sales J.

Following gender reassignment, transsexuals are often assessed in many different areas with regard to how they are functioning. However, there is little attention paid to the children they may have had prior to the operation and change in lifestyle. Children may present with problems related to the parents transsexualism, or with more generalised difficulties secondary to break-up of the family. A family of a transsexual father is described in which the children presented with difficulties and in which the intervention was successful.

Multistep treatment concept of transsexual patients

Experimental & Clinical Endocrinology & Diabetes. 104(6); 413-419, 1996.
Schlatterer K, von Werder K, Stalla GK.

Here we present a pragmatic multistep approach for the treatment of transsexual patients. The importance of an individually designed cross-gender hormone replacement therapy embedded in a multidisciplinary treatment concept, provided by psychiatrists, endocrinologists and surgeons, is demonstrated. Following this concept outcome of therapy has been improved in the last years. Over the last 5 years we have gained substantial experience in the cross-gender hormone treatment of transsexual patients. By continuous follow-up examinations and therapy adjustment the risk of side effects accompanying this therapy has been significantly minimised. This report is designed as a guideline to the clinical endocrinologist for the handling and treatment of transsexual patients. (63 ref)

Interdisciplinary concepts of surgical sex transformation in transsexual patients [In German]

Urologe - Ausgabe A; 35(1); 26-34; Jan 1996.
Sohn M, Bosinski H, Gouzoulis-Mayfrank E, Ebel H, van Saldern S, Loffler D, Jakse G.

From the introduction of the law on recognition of transsexuals (TSG) in 1980, over 1400 decisions were made by German regional district judges up to 1990. In over 90% of the cases the desired gender was accepted and attested officially. In the near future, a growing number of requests are to be expected. Generally, transsexual patients desire surgery to achieve a complete sex change. Since the foundation of an interdisciplinary gender dysphoria identity committee at our institution in 1989, we have developed criteria on indications, operative techniques and follow-up, which would over-tax a urology department, but which can be managed by an interdisciplinary team. Operative techniques may be regarded as well standardised in male-to-female transsexuals and may be performed by the urologist alone; in female-to-male transsexuals sex transformation remains a complex interdisciplinary challenge to urologists and plastic surgeons, mainly due to urethral complications. Continous psychiatric guidance and endocrinological monitoring of the patients facilitates indications for surgery and perioperative management.

Sexual differentiation of the human hypothalamus in relation to gender and sexual orientation

Trends in Neurosciences. 18(6)(204); 264-270; Jun 1995.
Swaab DF, Gofman MA.

Indicates that sex differences in the structures of the human hypothalamus and adjacent brain structures have been observed that seem to be related to gender, to gender problems such as transsexuality, and to sexual orientation (heterosexuality and homosexuality). Although these observations have yet to be confirmed, and their exact functional implications are not clear, they open up a whole new field of physiological structural/functional relationships in human brain research that has so far focused mainly on such relationships in pathology. Since the period of overt sexual differentiation of the human hypothalamus occurs between 4 years of age and puberty, this offers the possibility of interaction of a multitude of postnatal factors that act on sexual differentiation of the brain, not only of a genetic or hormonal, but also of a chemical and psychosocial nature.