Prediction of outcome in transsexualism by means of the Defense Mechanism Test and multivariate modeling: a pilot study

To elaborate the predictive value of the projective method using the Defense Mechanism Test in a 5-yr. follow-up study of 16 transsexuals, all subjects were approved for sex reassignment surgery and had completed the baseline assessments and the 5-yr. follow-up evaluation. Furthermore, we intended to create an outcome model based on the test data for prior patients wherein new consecutive applicants for sex change could be tested to predict the outcome in individual cases. Outcomes after five years showed that 62% of the transsexuals were judged as improved in a variety of areas of psychosocial functioning, 19% were unchanged, and 19% were worsened. Firstly, the analysis of the test data confirmed differences between the improved transsexuals and those who were not. Secondly, sex differences were found, with female-to-male transsexuals having a better outcome and being more homogeneous than their male counterparts. Thirdly, there was good correspondence in prediction of outcome between the model based on the Defense Mechanism Test and a clinical judgment made by a psychiatrist for two new applicants for sex reassignment surgery. It appears the Defense Mechanism Test has a predictive ability for patients with gender-identity disorder.     

EDITORS' INTRODUCTION

ABSTRACT

Transsexualism implies that an anatomically normal individual feels that he or she is actually a member of the opposite sex. Treatment usually includes real-life experience along with hormone therapy and sex reassignment surgery. Voice modification surgery may be necessary, as pass ability in general is still in a large extent dependent on the aspects of voice in transsexual people. Often male-to-female patients report being addressed in telephone conversations as their genetic gender, which is experienced as a disability. The purpose of this study was to evaluate the impact of voice on the quality of life in transsexuals.

In order to detect the disability caused by a voice disorder, the validated assessment method the Voice Handicap Inventory (VHI) was used. An additional question about the way patients were addressed in a telephone conversation was added.

As part of a study describing general health in transsexual persons, done at the Ghent University Hospital Belgium, a total of 48 patients were evaluated. In female-to-male transsexuals the median scores were very low, suggesting testosterone treatment led to an acceptable voice alteration. A higher serum LH level was significantly correlated with higher total, functional and emotional VHI scores. In male-to-female transsexuals the scores were significantly higher than those of the female-to-male transsexuals, but still there was no indication of a real disability/handicap. The extra telephone question was scored higher suggesting male-to-female transsexuals did experience a disability caused by their voice. From this study it is concluded that the VHI values did not demonstrate a handicapping effect.     

MMPI results of male candidates for transsexual surgery.

The MMPI was administered to a group of 27 male transsexual candidates for sex change surgery, and their test results were compared with those of 24 male kidney transplant surgical candidates and 26 males suspected of having a psychophysiological disorder. The data revealed a notable absence of psychopathology among the transsexuals as well as the kidney patients, while the psychophysiological patients showed the expected elevations in the Hypochondriasis, Depression, and Hysteria scales. The results were in keeping with previous research of male-to-female sex change candidates that reject the notion that transsexuals invariably suffer major emotional disturbance.     

Clinical utility of the Bem Sex Role Inventory (BSRI) in the Spanish transsexual and nontranssexual population

The aim of the study is to evaluate the usefulness of the Bem Sex Role Inventory (BSRI; Bem, 1974), an overall measurement of the cultural construct of masculinity and femininity, in the psychological assessment of Spanish transsexuals. Seventy male-to-female transsexuals (MF), 51 female-to-male transsexuals (FM), 77 control men, and 79 control women completed the Spanish version of the BSRI. Statistically significant differences between groups were only found on the femininity scale, on which MF transsexuals and control women scored significantly higher than FM transsexuals and control men. The results indicate that (a) only the femininity scale of the BSRI appears to be useful today for evaluating differences in the sex-role identification in Spanish controls and transsexuals; and (b) MF and FM transsexuals score as a function of their gender identity instead of their anatomical sex on the BSRI femininity scale.     

Clinical Utility of the Bem Sex Role Inventory (BSRI) in the Spanish Transsexual and Nontranssexual Population

The aim of the study is to evaluate the usefulness of the Bem Sex Role Inventory (BSRI; Bem, 1974), an overall measurement of the cultural construct of masculinity and femininity, in the psychological assessment of Spanish transsexuals. Seventy male-to-female transsexuals (MF), 51 female-to-male transsexuals (FM), 77 control men, and 79 control women completed the Spanish version of the BSRI. Statistically significant differences between groups were only found on the femininity scale, on which MF transsexuals and control women scored significantly higher than FM transsexuals and control men. The results indicate that (a) only the femininity scale of the BSRI appears to be useful today for evaluating differences in the sex-role identification in Spanish controls and transsexuals; and (b) MF and FM transsexuals score as a function of their gender identity instead of their anatomical sex on the BSRI femininity scale.     

Psychosocial Adjustment in Male-to-Female Transsexuals: An Overview of the Research Evidence

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.     

An Evaluation of the Validity of Rorschach Popular Responses as Differentiae of Ambulatory Schizophrenia

We compared MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, &; Kaemmer, 1989) profiles of 2 groups of adult biological men requesting sex reassignment surgery; 1 group was diagnosed with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) transsexualism and the other with gender identity disorder of adolescence and adulthood, nontranssexual type (GIDAANT). Although the mean profiles for the transsexual group did not demonstrate any psychopathology, the GIDAANT group showed moderate psychopathology. A cluster analysis indicated that 85% of the transsexual group showed low psychopathology and 47% of the GIDAANT group showed severe psychopathology. Neither the MMPI-2 results nor the DSM-III-R clinical evaluation support the conclusion of many authors that transsexualism is associated with severe personality disorder; rather, the data indicate that transsexualism and other gender identity disorders without persistent wish for sex reassignment differ significantly in degree of psychopathology.     

Utility of the MMPI-2 in assessing gender dysphoric patients

We compared MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles of 2 groups of adult biological men requesting sex reassignment surgery; 1 group was diagnosed with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) transsexualism and the other with gender identity disorder of adolescence and adulthood, nontranssexual type (GIDAANT). Although the mean profiles for the transsexual group did not demonstrate any psychopathology, the GIDAANT group showed moderate psychopathology. A cluster analysis indicated that 85% of the transsexual group showed low psychopathology and 47% of the GIDAANT group showed severe psychopathology. Neither the MMPI-2 results nor the DSM-III-R clinical evaluation support the conclusion of many authors that transsexualism is associated with severe personality disorder; rather, the data indicate that transsexualism and other gender identity disorders without persistent wish for sex reassignment differ significantly in degree of psychopathology.     

The Legal Status of Transsexuals in Turkey

ABSTRACT

The development of the legal regulations concerning transsexuals in Turkey can be analysed in three phases. The first phase was prior to 1988 when there were no legal parameters at all. The second phase started in 1988 when certain changes made in the Turkish Civil Code (TCC) for the first time gave people who had already undergone sex reassignment surgery (SRS) the possibility to enter this change into the birth register. The third phase commenced in 2002 when the new Turkish Civil Code came into force.¹ Art.40 of the Code now regulates the pre-conditions for a surgery and the procedure for getting a court authorisation in order to be operated as well as the procedure for entering the sex change into the birth register after the operation. Following remarks aim at briefly explaining these historical developments in Turkish law and presenting the current legal situation in Turkey with respect to transsexuals. The deficiencies in the existing regulation and possible ways of surmounting these will also be examined.     

Transsexuals and Pseudotranssexuals

SUMMARY

This article was first published in Archives of Sexual Behavior, vol. 7, no. 4, 1978, pp. 263–272. Prince admits to being attracted by the idea of sex reassignment for herself at the time of the publicity given to the case of Christine Jorgensen. However, the development of her philosophy that the central issues were to do with gender (the psycho-social) and not sex (anatomy and physiology) leads her to the view that it is perfectly possible for a male to be a woman without having sex surgery. She speaks out forcefully against sex reassignment, arguing that it is not appropriate for nine out of ten of those requesting it and writes of “so-called” or pseudo transsexuals. Susceptible transvestites are seduced by the publicity given to the topic into thinking it is the solution to their problems.     

Sex Reassignment Technology: The Dilemma of Transsexuals in Islam and Christianity

The birth of people with confused or ambiguous sex makeup as a biological fact since the annals of history has posed the challenge of accommodating them within the binary gender of sociocultural systems. In this process, the role of religion as a defining factor in social engineering has been paramount. Major religions, such as Islam and Christianity, have addressed this issue within the frame of their God-ordained laws by devising a set of moral and legal imperatives specific to the “third gender.” Modern developments in medicine and biology, however, have made sex reassignment possible for this category of people, today called transsexuals. The question is: How do Islam and Christianity respond to it. After presenting an analytical view of both Muslim scholars and Christian religious authorities on the legitimacy of sex reassignment for transsexuals, this paper attempts to explore if such a dilemma can be resolved.     

Anger and aggression during role-playing: Gender differences between hormonally treated male and female transsexuals and controls

A role-playing study on anger was conducted in order to identify the influence of sex hormones on individual and gender differences in irritation, anger arousal, and aggression. Different groups were studied: female-to-male and male-to-female transsexuals, with either group tested after 3 months of cross-sex hormone treatment, and untreated control women and men. All subjects were exposed to a 35-min videotape of an individual tested in an aversive, physically stressful, and frustrating situation in the laboratory. While watching, subjects were asked to imagine being in the same situation. Meanwhile, cardiovascular responses were registered and the intensity of moods and aggressive behaviour were assessed. Apart from a clear effect upon cardiovascular arousal and anger-related moods, there were also some interesting differences between the four groups, the most interesting one being a stronger aggressive response in the female-to-male transsexuals. Furthermore, interesting information was gathered with respect to the issue of whether role-playing and actual experimentation provide valid tests of anger and aggression in real life. © 1995 Wiley-Liss, Inc.     

A Systems Approach to the Social Difficulties of Transsexuals in Hong Kong

This paper identifies social difficulties commonly faced by a group of forty-two Hong Kong transsexuals who had applied for sex reassignment surgery. It describes the use of a systems perspective to conceptualize their problems and a structural family therapy approach to social work intervention.     

Evolution of Gonadal Axis After Sex Reassignment Surgery in Transsexual Patients in the Spanish Public Health System

ABSTRACT

Although the effects of hormone therapy on cardiovascular risk factors and bone metabolism have been studied, data are lacking on the gonadotropin profile after gonadectomy in the sex reassignment process (SRP). Accordingly, whether measurement of the gonadotropin profile is useful in order to adjust the postsurgical dose of gonadal hormones is unknown. We studied the evolution of LH, FSH, prolactin, testosterone, and estradiol in 50 transsexual persons, 41 male-to-female transsexuals (MtF) and 9 female-to-male transsexuals (FtM), following a proto-colized regimen of hormone therapy for 12–24 months before and after genitoplasty. The increase in gonadotropins after surgery was greater in the FtM than in the MtF (66% vs. 50%), with the increase continuing more than one year after surgery. No variable was significantly associated with this different level of gonadotropins.     

The role of anxiety and depression in the irritable bowel syndrome

Using a reliable and valid structured diagnostic interview scale (ADIS-R), and patients with careful medical characterization, we found significantly more diagnosable psychopathology, particularly anxiety disorders, among treatment seeking patients with irritable bowel syndrome than among comparable age and sex samples of treatment seeking patients with Inflammatory Bowel Disease. Significant differences were also found on the Hamilton Anxiety Rating Scale and Hamilton Rating Scale for Depression between IBS patients and the IBD patients and controls, who did not differ. Comparable levels of psychiatric disorder among parents of probands were found in all three groups. The results are consistent with Latimer's (1983) notion of IBS patients being a subclass of 'neurotics'.     

Enlarged Range of Free Flaps for Phalloplasty in Transsexual Reassignment Surgery

ABSTRACT

Our concept for complete phalloplasty which we applied in 66 female-to-male transsexuals, using free prelaminated osteofasciocutaneous fibula or fasciocutaneous forearm flaps, consisted of the following three operative stages:

1. mastectomy, ovariohysterectomy, urethra lengthening, colpectomy, and neourethra prelamination

2. after 3–6 months, neophallus creation with free sensate and prelaminated osteofasciocutaneous fibula (n = 41) or radial forearm flaps (n = 25)

3. 3–6 months later, urethral connection, neoscrotum formation and testicle prosthesis implantation.

Results: After mastectomy 2 hematoma had to be removed, and twice colpectomy revision was needed because of hematoma. No complications occurred after ovariohysterectomy. Partial flap necrosis took place in 1 patient of the forearm group and total necrosis in 2 patients of the fibula group. Eleven patients presented urethral stricture, and 9 a fistula. In 7 patients an operative stricture expansion was required, and in 6 patients surgical closure of the fistula. Overall patients' satisfaction was excellent.

Conclusions: The applied results demonstrates the effectiveness of such a multistage and interdisciplinary approach for female-to-male transsexual and it shows, that the fibula flap is an equal routine method extending the therapeutical range of gender assignment operations in female-to-male transsexuals.     

Trans employees,transitioning, and job satisfaction

While trans employees have become more widely recognized in society, our understanding of their work experiences remains underdeveloped. In the current study, we investigate whether transitioning is associated with job satisfaction in England, Wales and Scotland. Using longitudinal data collected before and after sex reassignment surgery associations between job satisfaction and mental health/life satisfaction are examined for trans men and women. The estimations suggest that employees experience higher job satisfaction, mental health and life satisfaction after sex reassignment surgery than before. In addition, the estimations suggest that after sex reassignment surgery, the associations between job satisfaction and mental health/life satisfaction are stronger than before. Moreover, the estimations suggest that employees not only experience higher job satisfaction after sex reassignment surgery, but also during transitioning. The results suggest that, firms should not treat transitioning employees in a biased way, since their transition might entail positive personal and workplace advancements.     

Creativity and Psychopathology: Sex Matters

The association between creativity and psychopathology has, for decades, been a focus of heated debate fuelled by contradictory findings. Nevertheless, the findings suggest complex associations between creativity and psychopathology. Other studies have investigated the association between creativity and sex, with inconsistent results. The aim of this study was to investigate the influence of sex on the association between creativity and psychopathology. In total, 106 participants (37 men and 69 women) were administered the Symptom Check List (SCL90-R) and the CREA test of creativity. There were no significant associations in the total sample between the variable creativity and the psychopathology scales. Strikingly, when the sample was divided by gender, a moderate-to-high significant positive association between creativity and psychopathology was found among men. Previously, the associations between creativity and gender and between creativity and psychopathology were studied in relative isolation from each other, rather than together as the main focus of research. Our results suggest that the complex associations between psychopathology and creativity differ between men and women.     

United States and Japanese college students' attitudes toward seeking professional psychological help

The purpose of the study was to find how nationality, sex, and past experience of seeking professional psychological services are related to attitudes toward seeking professional psychological help. Three hundred Japanese college students and 300 US college students responded to the Attitudes Toward Seeking Professional Psychological Help (ATSPPH) questionnaire. The ATSPPH consists of four subscales: Need (recognition of need), Stigma Tolerance (the degree of tolerance against stigma associated with help‐seeking action), Openness (interpersonal openness), and Confidence (confidence in mental health professionals). As predicted, past experience of seeking professional psychological service and sex were important predictor variables of performance on the ATSPPH scales. Those who had past experience of seeking professional psychological help had more favourable attitudes toward seeking professional psychological help than those who never consulted psychological professionals. Similarly, in testing the past experience separately with the two nation groups, past experience with seeking professional psychological services was found to be a predictor of the overall attitudes toward seeking professional psychological help among Japanese and US participants. Furthermore, Japanese participants with past experience also showed greater recognition of need for professional psychological help and confidence in psychological health professions than Japanese without past experience. The degree of stigma tolerance associated with help‐seeking behaviour and the tendency of interpersonal openness, however, did not differ between Japanese participants with and without the past experience of seeking professional psychological services. The same results were also found among the US participants. In terms of sex as a predictor variable, females tended to have more positive attitudes toward seeking professional psychological help than males. There was a significant nationality by sex interaction effect. US females had significantly more favourable attitudes than the other three groups, indicating that there was sex difference in help‐seeking attitudes in the US group, but not in the Japanese group. If the sex variable is ignored, Japanese students have less favourable overall attitudes toward seeking professional psychological services than US students. Other results and limitations of the study are discussed.     

Similarities in becoming: transsexuals and adolescents

The Gender Identity Service (located in Boston, Massachusetts) is an evaluative and counseling unit designed to provide full services including sexual reassignment to transsexuals. In that capacity, since the spring of 1972, we have seen over 120 transsexuals. During this time we have been impressed with behavioral similarities between our population of transsexuals and adolescents. This emerging observation provided impetus for the present paper. After carefully reviewing our caseload material it is our contention that indeed psychological, biological and sociological similarities do exist. Through a comparison of these, we hope not only to make transsexual behaviors more comprehensible but also to underscore the importance of the adolescent years for the development of adult gender identity. Using primarily an ego psychoanalytic approach, the paper attempts to demystify the diagnosis of transsexual by pointing to its dynamic similarities with adolescence.