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Male-to-Female and Female-to-Male
Transsexuals: A Comparison
G. Kockott, M.D.2,3 and E.-M. Fahrner, Ph.D.2
Male-to-female and female-to-male transsexuals differed with respect to social, partnership, and sexual behavior, independently of whether they had had surgery. Female-to-male transsexuals more often had close ties to their parents and siblings, established stable partnerships more frequently solely with the same biological sex, and were more satisfied sexually. When they first consulted a physician about sex change, they were already more integrated socially. By the time the follow-up assessment took place, maleto -female transsexuals were as integrated socially as their female-to-male counterparts. The differences in partnership behavior between male-to-female and female-to-male transsexuals were not altered as a result of surgery, despite the better surgical match with which surgery provides male-to-female transsexuals in comparison with their female-to-male counterparts. The reasons for the relational differences remain unclear and raise issues in the areas of develop mental psychology and genetics.
KEY WORDS: male-to-female transsexuals; female-to-male transsexuals; psychosocial stability; sex reassignment surgery.
The study was supported by a grant from the Wilhelm-Sander-Stiftung. 1Dedicated to Prof. D. Ploog for his 65th birthday. 2Department of Psychiatry, Technical University, Ismaningerstrasse 22, 8000 Munchen 80, Germany.
3To whom correspondence should be addressed.
Differences in the behavior of male-to-female and female-to-male transsexuals were described in earlier studies. The first comprehensive survey was carried out by Pauly in 1974. Drawing on the available literature and his observations of his own patients, he gave a detailed description of female-to-male transsexuals. In the course of the study he became aware of the higher proportion of stable partnerships formed by female-to-male transsexuals in comparison with male-to-female transsexuals. This impression was verified by other authors (Steiner and Bernstein, 1981; Spengler, 1980; Studer et al., 1980, Krohn et al., 1981). According to Steiner and Bernstein (1981) these relationships are often formed long before gender reassignment surgery. On the basis of a matched control study, Fleming et al. (1985) concluded that the partnerships of their 22 female-to-male transsexuals were comparable to normal heterosexual partnerships. Pauly (1974) found that female-to-male transsexuals behaved exclusively homosexually, according to their biological gender. Although this topic is not dealt with extensively in the literature, all the findings seem to agree (Steiner and Bernstein, 1981; McCauley and Erhardt, 1984). The female-to-male transsexuals are usually fully accepted as male by their female partners according to Pauly (1974), Steiner and Bernstein (1981), and Studer et al. (1980), while these partners characterize themselves as being heterosexually oriented (Green, 1974; Steiner and Bernstein, 1981). Pauly (1974) had the impression that female-to-male transsexuals assume the new role more naturally than male-to-female transsexuals. He is in agreement with Walinder (1967) who described male-tofemale transsexuals as being more asthenic, hysteroid, and infantile than female-to-male transsexuals. To Pauly, female-to-male transsexuals are "better adjusted, freer of paranoid trends and more realistic in their appraisal of what is possible for them." This description seems to be confirmed by the results of Dixen et al. (1984).
These studies show that female-to-male transsexuals seem to differ from male-to-female transsexuals in their sexual and partnership behavior as well as in their psychosocial stability. In this survey we report the differences we found between male-to-female and female-to-male transsexuals in the course of a comprehensive follow-up study.
The follow-up study included all patients who (during the period from January 1970 to December 31, 1980) were examined by one of the authors in a Psychiatric Outpatient Clinic and diagnosed according to the diagnostic criteria of the DSM III (American Psychiatric Association, 1980) as transsexuals. Particular care was taken to differentiate between transsexualism, transvestitism, and homosexuality, using the criteria of Lundstrom et al. (1984) in addition to the DSM-III criteria. According to these criteria a total of 80 patients were selected from the case histories. Of the 80 patients, 59 (74%) were interviewed (The data of one of them could not be used.); 4 patients (5%) refused to take part in the investigation, with 4 patients (5%) the interview could not take place for organizational reasons, and 3 patients (4%) had died. The addresses of 10 patients (13%) could not be ascertained. The average duration of the follow-up period from time of diagnosis was 5.5 years for the total sample. Of the 58 transsexuals interviewed, 37 were male-to-female transsexuals and 21 female-to-male transsexuals. Further biographical details of the sample are contained in Table I.
Table I. Description of Sample
Total follow-up sample of transsexuals (N = 58) Variable M-to-F (n = 37) F-to-M (n = 21) Age in years (x) 24.9 32.1 (SD 8.2) (SD 6.4) Status Single 25 (68%) 16 (76%) Married 4 (11%) 4 (19%) Divorced 8 (22%) 1 (5%) No. of transsexuals With children of their own 7 (20%) 1 (5%) Without children of their own 28 (80%) 19 (95%) Occupation Salaried employee 17 (46%) 5 (24%) Civil servant 4 (11%) 2 (10%) Manual occupation 9 (24%) 10 (48%) Self-employed 4 (11%) 2 (10%) Student 3 (8%) 2 (10%)
At the time when the diagnosis was made, both groups differed significantly with respect to social integration, as defined by the PIT rating scale (see Procedure). Proportionately more female-to-male transsexuals were socially integrated (Wilcoxon: Z = 2.6947, p < 0.007, two-tailed, 16 female-to-male, 30 male-to-female). Other pre-follow-up differences could not be statistically compared due to considerable gaps in the data. Two thirds of the female-tomale transsexuals (12 of 19), but only one third of the male-to-female transsexuals (12 of 36) had close, intense relationships with their families. Similar differences were found with respect to partnership behavior; two thirds of the female-to-male transsexuals (12 of 19) had lasting partnerships (more than 6 months) with which they were predominantly satisfied (10 of 12). Only half of the male-to-female transsexuals (18 of 37) had lasting partnerships, and the majority reported dissatisfaction with the partnerships (16 of 18). These partners often originated from marriages that existed before the strong wish for gender change developed. Eighty percent of femaleto -male transsexuals were sexually satisfied (13 of 16), whereas 80% of maleto -female transsexuals were dissatisfied (22 of 28).
The basis of the follow-up was a personal interview. With few exceptions, the interviews were not conducted by those who had initially treated the patients. The 2- to 3-hr interview ("Transsexuals Follow-up Interview TFI) consisted of 125 questions covering areas of life such as occupation, partnership and sexual behavior, relationships with the family, circle of friends, relationship to the sex role, and somatic conditions. The TFI is a semistructured interview with open-ended and closed questions. After the interview, the interviewer evaluated the patients' social and mental adjustment in the nine relevant areas covered by the interview according to a four-stage rating scale specially developed to measure "Psychosocial Integration of Transsexuals" (PIT). This rating scale was developed according to the scale used by Hunt and Hampson (1980). Fifteen interviews were conducted by two interviewers, who rated the persons separately. The overall interrater reliability was r = 0.79 using the Spearman-Brown prediction formula. In the nine psychosocial areas covered by the interview, patients were evaluated as to how they coped socially and emotionally. The evaluation of the degree of the psychosocial difficulties was carried out according to a manual. A total number of points could be calculated from the nine subscales of the PIT. The data for assessment 1, when the diagnosis was made (usually after the first 5 consultations), were collected retrospectively from case histories. For these a shortened version of the TFI "Evaluation Sheet for Case Histories" (ECH) was used as well as the rating scale PIT.
Comparison of the Psychosocial Situation of Male-to-Female and Female-toMale Transsexuals at the Time of Follow-Up Assessment
Table II. Differences Between M-to-F and F-to-M Transsexuals at the Time of the Follow-Up Assessment
M-to-F F-to-M x2 p (two-tailed) Variable n % n % Close contact to family 15/35 43 14/20 70 2.752 0.097 Lasting partnership 10/37 27 12/21 57 3.961 0.047a Partner informed about transsexualism 6/10 60 12/12 100 3.486 0.062 Sexual satisfaction 22/36 61 18/20 90 3.938 0.047a Suicide attempts 8/37 21 1/21 5 2.905 0.088
aSignificant at the 5% level.
Table II shows that female-to-male transsexuals are significantly more likely to be in lasting partnerships (p ² 0.05) and to derive sexual satisfaction from them (p ² 0.05) than are male-to-female transsexuals. All 12 partners of the female-to-male transsexuals belonged to the same biological sex, whereas only 6 of 10 partners of the male-to-female transsexuals belonged to the same biological sex. According to the statements made by the femaleto -male transsexuals, their partners did not doubt the masculinity of the transsexuals. These uniform accounts contrasted with the varying descriptions of male-to-female transsexuals with steady partners about the kind of relationship with their partners. Related to these findings were trends suggesting that female-to-male transsexuals were more likely to tell their partners about their transsexualism (p ² 0.06) and to maintain close contact with their families (p ² 0.10) than were male-to-female transsexuals. Another trend, attempted suicide, was found to occur more often among male-to-female than female-to-male transsexuals (p ² 0.09). All except one of the attempted suicides took place before sex reassignment surgery. In their psychosocial integration, as measured by the PIT, there were no differences between the two groups at the time of follow-up.
Differences Between Male-to-Female and Female-to-Male Transsexuals Who Had Had Surgery at the Time of the Follow-Up Assessment
Some of the differences between male-to-female and female-to-male transsexuals could have been due to the greater difficulties of male-to-female transsexuals before gender reassignment surgery. If so, they should have disappeared after surgery; differences with respect to social relationships however continued to exist. More female-to-male transsexuals who had had surgery had steady sexual partners (11 of 11 at the time of follow-up) than male-to-female transsexuals (6 of 14) who had surgery (x2 = 6.80, p < 0.009), and the partnerships were of significantly longer duration (p < 0.014, Wilcoxon). All their partners were informed about their transsexuality, by contrast with 60(%of the male-to-female transsexuals. There were no longer any differences with respect to evaluation of their sex life: both groups reported satisfactory sex. When psychosocial integration was evaluated (PIT) there were no differences between the male-to-female and female-to-male transsexuals who had undergone surgery.
The differences between male-to-female and female-to-male transsexuals described in previous literature (Pauly, 1974; Steiner and Bernstein, 1981; Studer et al., 1980; Krohn et al., 1981; Fleming et al., 1985) is confirmed in this follow-up study. These differences could be seen when the diagnosis was made. Male-to-female transsexuals were clearly having more difficulties with social integration (measured with the PIT) than female-to-male transsexuals when they consulted a doctor for the first time. This difference in social integration no longer existed at the time of the follow-up assessment: By then male-to-female transsexuals had caught up with female-to-male transsexuals with respect to social integration. The results of Blanchard et al. (1985) can be similarly interpreted.
Gender reassignment surgery is shown to be an influencing factor. The increase in sexual satisfaction for male-to-female transsexuals shown here could be interpreted as a result of gender reassignment surgery. Contrary to expectations, the differences in partnership behavior between male-to-female and female-to-male transsexuals did not change as a result of surgery. This is particularly surprising as the operation, especially for the male-to-female transsexuals, seems to provide far better opportunities for penile-vaginal sexual intercourse (creation of a neovagina) than for female-to-male transsexuals, who usually have no neophallus. We are therefore left with an apparent contradiction: Female-to-male transsexuals more often had stable partnerships that were comparable to traditional partnerships (Fleming et al., 1985) in spite of unfavorable anatomical conditions.
This paradox might be explained as follows: Long before the operation, female-to-male transsexuals were often living convincingly in the male gender role and during this time developed lasting partnerships. In the course of time their partners were fully informed about their transsexualism, were themselves interested in the operation, and accompanied the transsexual partner during the entire treatment period, and also after the operation. By comparison, male-to-female transsexuals usually only embarked on lasting sexual relationships in the aspired gender role after gender reassignment surgery and often seemed to encounter disappointments. There also seem to be sex differences in partner expectations; even in the partnerships of male-tofemale transsexuals there seem to be sex differences in the behavior of partners. The rare partnerships between male-to-female transsexuals and female partners seem to last longer than partnerships with male partners.
Differences in partnership behavior may in part be due to the fact that a male-to-female transsexual has greater difficulties than a female-to-male transsexual in living in the aspired gender role for a long time and in finding an understanding partner before gender reassignment surgery; but why do male-to-female transsexuals continue to have difficulties in partnership behavior after surgery? Why are female-to-male transsexuals more stably adjusted socially when they first come to see a doctor about gender reassignment, and why are they more cooperative during the treatment period? Significantly more of our female-to-male transsexuals who had undergone surgery had not had a university education (p < 0.027) and were therefore significantly more often in manual occupations (p < 0.044). However, it seems questionable whether this social class difference can explain the differences cited here. Female-to-male transsexuals also seem to be less aggressive on their own behalf than male-to-female transsexuals. The editors and co-workers of a German magazine for transsexuals are exclusively male-to-female transsexuals, even though the editors had repeatedly asked female-to-male transsexuals to cooperate with them. The differences in partnership behavior noted here between male and female transsexuals are similar to differences noted between male and female homosexuals (Saghir et al., 1969). Are these modes of behavior related to maleness or femaleness? These differences could be due to behavior patterns that were genetically determined and acquired during the individual's early development, which prevail in inspite of the aspired or accomplished gender change.
The differences are also of relevance for therapy. If gender reassignment surgery is indicated for a female-to-male transsexual, the prognosis is generally better than for male-to-female transsexuals, since integration in the aspired gender role has often been achieved before the first contact is made with a doctor about the possibilities of a sex-change operation.
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