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Transsexuals Who Have Not Undergone Surgery: A Follow-Up Study
G. Kockott, M.D.,3,4 and
E.-M. Fahrner, Ph.D.3
Transsexuals who had not undergone surgery, although it had been offered to them providing they fulfilled the usual requirements, were classified into various subgroups, measured according to their attitude towards sex reassignment surgery: they were transsexuals with an unaltered wish for surgery, transsexuals who were ambivalent towards surgery (hesitating patients), and transsexuals who had relinquished their wish for surgery and lived in the initial gender role. Whereas transsexuals with an unaltered wish for surgery did not differ substantially from transsexuals who had had surgery, the hesitating patients were noticeably older, more often married, more often had children of their own, their partnerships were of long duration, and exclusively with partners of the opposite biological sex. These characteristics were seen when the diagnosis was first made. They can therefore be considered prognostic criteria for this subgroup. Transsexuals who relinquished their wish for surgery did not differ substantially from transsexuals with an unaltered wish for surgery. The reasons for relinquishing the wish for surgery were individual or could not be clearly established. At the time of follow-up, all transsexuals who had not undergone surgery indicated that they were experiencing the same degree of difficulty with respect to social adjustment as at the time of diagnosis. Slight improvements were seen in patients with an unaltered wish for surgery. Significant changes were seen only in transsexuals who had surgery. Transsexuals who have not had surgery and have no present wish for it are in the minority. Hesitating patients have a particular need for psychotherapy.
KEY WORDS: transsexual; prognostic criteria; follow-up; sex-change surgery. 1The study was supported by a grant from the Wilhelm-Sander-Stiftung. 2Dedicated to Prof. D. Ploog for his 65th birthday. 3Department of Psychiatry, Technical University, Mohlstrasse 26, 8000 Munchen 80, Germany.
4To whom correspondence should be addressed.
Long-term follow-up studies of transsexuals who have not had surgery are rare. Meyer and Reter (1979) were the first to carry out a detailed study of transsexuals who had not had surgery. From the results obtained they concluded that gender reassignment surgery does not achieve more for transsexuals therapeutically than if they adopt a policy of wait and see and are admitted to a program that could later make gender reassignment surgery possible. This report has been criticized, particularly by Fleming et al. (1980) The criticism is directed partly at the system used by Meyer and Reter for evaluating social integration; it is also pointed out that the results from the groups formed by Meyer and Reter do not provide suitable material for drawing conclusions about the therapeutic effectiveness of gender reassignment surgery. In 1981, using the data from a follow-up examination, Krohn described 13 male-to-female transsexuals who had not yet had surgery and whose diagnosis had been established 4 to 8 years before. Nine of these, mostly over 40 years old, lived in their aspired role, in which they were accepted; they neither had nor wanted sexual contacts. They still said they wanted surgery, but had not actively taken any steps in that direction for years. They were described as mentally stable and their socioeconomic situation free of problems. Lundstrom (1981) conducted a thorough follow-up study of 31 patients, who at least 3 years earlier had wanted gender reassignment surgery. According to his results patients "with conditions difficult to distinguish from effeminate homosexuality or classical transvestism" can come to terms relatively well with their biological sex, whereas cross-dressing behavior of a compulsive type is an indication for sex reassignment. McCauley and Erhardt (1984) reported on the follow-up of 15 female-to-male transsexuals, of whom 6 who had not had surgery, and did not live in the male role, or did not live in it all the time. All six reported a recurrence of strong transsexual wishes in stress situations or when they were depressed.
From these reports it can be concluded that in follow-up studies transsexuals who have not had gender reassignment surgery show a variety of attitudes towards it: Some still urgently want surgery, others are ambivalent towards surgery, and some have decided against it.
The aim of our investigation was to see whether subgroups of this nature could be ascertained and to determine how they differed. In view of the results of the Meyer and Reter (1979) study, we were particularly interested in the question of whether sex reassignment surgery actually influences the psychosocial situation of transsexuals.
This survey included all patients who were examined by one of the authors in a Psychiatric Outpatient Clinic during the period from January 1, 1970 to December 31, 1980 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 homo-sexuality using the criteria of Lundstrom et al. (1984) in addition to the DSM III criteria. The first consultations had to be at least 2 years prior to the follow-up. According to these criteria a total of 80 patients were selected from the case histories. In the course of consultations with the patients they were all offered the possibility of gender reassignment surgery on condition that they fulfill the usual requirements such as 1 or 2 years counseling, a "real-life test," and hormone treatment (see Sigush et al., 1979; Fahrner and Kockott, 1984).
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. In the 2 to 3 hour interview (Transsexuals Follow-up Interview, TFI) the following areas of life were covered by 125 questions: occupation, partnership and sexual behavior, relationship with family, circle of friends, relationship to the sex role, and somatic conditions. The TFI is a semistructured interview with open and closed questions. After the interview, the interviewer evaluated the patient's social and mental adjustment according to a specially developed four-stage rating scale (Psychological 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 their degree of the psychological difficulty was carried out according to a manual. A total number of points was calculated from the nine subscales of the PIT.
Times of Assessment
Data are available for three assessments of the transsexuals who underwent gender reassignment surgery and data for two assessments of the transsexuals who did not have surgery. Information on Assessment 1 (A1), when the diagnosis was made (usually after the first five consultations), are available for both groups. Details of Assessment 2 (A2), in the period shortly be fore gender reassignment surgery, are only available with regard to the transsexuals who underwent surgery. The data for both assessments were collected retrospectively from the 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. Assessment 3 (A3) is the follow-up study.
Description of Sample
Of 80 patients (100%), 59 (74%) were interviewed. Four patients (5%) refused to take part in the investigation, four patients (5%) could not be interviewed for organizational reasons, and three patients (4%) died. The addresses of 10 patients (13%) could not be ascertained. Of the patients interviewed, 32 underwent sex reassignment surgery, 27 transsexuals had not yet had surgery. The average duration of the follow-up period, beginning from the time the diagnosis was made, was 5.5 years for the total sample. For the group of patients who had had surgery, it was 6.5 years, and for the group of patients who had not had surgery 4.6 years.
Table I. Demographic and Socioeconomic Status of Transsexuals (N = 58)
Transsexuals who had not had surgery (n = 26) Unchanged Transsexuals wish who have for surgery Hesitating had surgery Variable (n =32) (HP) n = 7 n = 12 n = 7 Age in years 35.5 40.3 31.7 3l.8 (SD = 13.1) (SD = 9.4)b (SD = 10.2)b (SD = 6 5)b Sex Male to female l8 (56%) 6 (86%) 9 (75%) 4 (57%) Female to male 14 (44%) 1 (14%) 3 (25%) 3 (43%) Status Single 21 (66%) 3 (43%) 11 (92%) 6 (86%) Married 3 (9%) 4 (57%)a 1 (8%)a 0 (0%) Divorced 8 (25%) 0 (0%) 0 (0%) 1 (l4%)
Number of transsexuals
of their own 3 (9%) 4 (57%)a 0 (0%)a 1 (14%) without children
of their own 29 (91%) 3 (43%) 12 (100%) 1 (86%) Occupation
employee 14 (44%) 2 (29%) 3 (25%) 3 (43%) Civil servant 3 (9%) 2 (29%) 0 (0%) 1 (14%) Manual
occupation 11 (34%) 0 (0%) 5 (42%) 3 (43%) Self-employed 2 (6%) 3 (43%) 1 (8%) 0 (0%) Student 2 (6%) 0 (0%) 3 (25%) 0 (0%) aSignificant difference (5% level) between HP and UWS. bDifference at the 10% level between HP, UWS, and IG.
The Subgroups (Table l)
At the time of the follow-up assessment (A3), three subgroups could be differentiated among the patients who had not had surgery according to their wish for gender reassignment surgery: (i) Patients with an unchanged wish for surgery during the whole follow-up period (UWS: 12 patients, 9 male-to-female and 3 female-to-male transsexuals). They had not yet fulfilled all the requirements for surgery such as intensive counseling, real-life test, etc. At the time of interviewing most of them were at the real-life test stage. (ii) Patients who remained undecided during the whole follow-up period, the hesitating patients (HP: 7 patients, of whom 6 were male-to-female transsexuals and one was female-to-male). They lived mainly in their biological sex role. (iii) Patients who at the time of the follow-up assessment had not wanted gender reassignment surgery for some time. They lived in their original biological sex (IG = initial gender: 7 patients, 4 male-to-female and 3 female-to-male transsexuals). Only one patient lived completely in the aspired gender role without gender reassignment surgery. This patient is not included in the following comparison.
Table II. Differences Between the Three Subgroups of Transsexuals Who Have Not Had Surgery (UWS, HP, IG) at the Time of the Follow-Up Assessment (A3)
Variable Subgroups Phi Fisher two-tailed P UWS HP UWS/HP Own income 7 of 12 7 of 7 0.456 0.106 (58%) (100%)
sufficiency 6 of 12 7 of 7 0.519 0.044a
partners 0 of 5 2 of 2 1.0 0.048a (0%) (100%)
High value placed
on sex 9 of 12 2 of 7 0.454 0.077
identity 12 of 12 3 of 7 0.676 0.009b (100%) (43%)
Satisfied with home
situation due to
transsexuality 12 of 12 3 of 77 0.676 0.009b (100%) (43%) UWS IG
of long duration 0 of 9 2 of 4 0.640 0.077 (0%) (50%) HP IG
satisfaction 1 of 6 6 of 77 0.691 0.029a
sexual arousal 2 of 7 6 of 7 0.774 0.103
aSignificant at the 5% level.
bSignificant at the 1% level.
Differences Between the Subgroups
at the Time of the Follow-Up Assessment The hesitating patients seemed to be different from the others. They tended to be older than the other subgroups, they more often had their own children and were significantly more often married than the UWS patients (Table I). The socioeconomic situation of the hesitating patients was more stable. They more frequently tended to have an income of their own than with patients with an unchanged wish for surgery. They managed significantly better financially. The current partnerships of the hesitating patients, although mainly unhappy ones, had existed for a significantly longer period and, compared to patients within an unchanged wish for surgery, were only with sex partners of the opposite biological sex. Hesitating patients were significantly less satisfied sexually than the IG patients. They also felt less affinity towards the aspired gender. They were significantly less satisfied with their home situation due to their transsexuality (Table II).
The PIT questionnaire for determining the psychosocial adjustment of transsexuals showed no difference between the three subgroups at the time of the follow-up assessment, although the IG group achieved slightly better total scores (see Fig. 1).
Development of the Three Subgroups
During the Follow-Up Period
The patients' descriptions of their situation given at the time the diagnosis was made (A1) were compared with those given at the time of the follow-up assessment (A3).
For patients with an unaltered wish for surgery (UWS), job satisfaction had increased during this time and their transsexuality was more often accepted by family members. Partner relationships deteriorated in that partnerships that had existed before the wish for gender reassignment surgery was clearly expressed came to an end. In the PIT (Fig. 1) the total score improved from 20.2 to 18.7. This difference is not, however, significant. Both scores still indicated obvious difficulties with psychosocial adjustment.
Fig. 1. Psychosocial adjustment of operated and three groups of unoperated transsexuals (rating scale PIT).
For hesitating patients (HP), neither the follow-up data nor the PIT showed any changes.
Patients with no present wish for surgery (IG) showed an increase with respect to sexual satisfaction. There were no significant changes in the PIT. When the diagnosis was made this subgroup was psychosocially the best adjusted of all the subgroups. They reported only a few psychosocial difficulties
The Subgroups at the Time the Diagnosis Was Made We assumed that the subgroups described would be distinguishable when the diagnosis was made. To confirm this, the statements made at the time of the diagnosis (A1) by the three subgroups of patients, UWS, HP, and IG, that were formed later were compared with one another. Since this involved a retrospective evaluation of case histories, only a descriptive comparison is possible due to incomplete data. Again it was the group of patients who later hesitated about surgery who were noticeably different when the diagnosis was made: Their average age was considerably higher than that of the other groups of transsexuals who had not had surgery and the majority were married men with children of their own. Compared with patients with an unaltered wish for surgery, of whom only half were satisfied with their jobs when the diagnosis was made, the hesitating patients and those who later no longer wished for sex reassignment surgery (IG) were all satisfied with their jobs when the diagnosis was made. The PIT (Fig. 1) does not show significant differences, although, as already described, the psychosocial integration of the IG group was clearly better than that of the other subgroups when the diagnosis was made.
Does Sex Reassignment Surgery
Influence the Psychosocial Situation of Transsexuals? Indirect indications of the effect of sex reassignment surgery can be obtained by comparing the statements of patients who have had surgery with those of patients with an unaltered wish for surgery at the time of the follow up assessment. We therefore compared the statements of the 32 patients of our sample who had had surgery with those of the UWS subgroups (12 patients) who were particularly suitable for comparison as they showed no differences with respect to sociodemographic data (see Table I).
Table III. Differences Between Transsexuals Who Have Had Surgery (SU) and Patients with Unchanged Wish for Surgery (UWS) at the Time Follow-Up Assessment (A3)
Variable SU UWS Correlation x2 P (two-tailed)
No employment 2 of 32 4 of 12 3.379 0.066
sufficiency 27 of 29 6 of 12 7.484 0.006b (93%) (50%) Sexual satisfaction 28 of 32 5 of 11 5.924 0.015a (87%) (45%) Content with aspired gender 31 of 32 5 of 10 10.112 0.002b (97%) (50%) Well adapted to gender role 30 of 32 5 of 12 11.525 0.001c (94%) (42%)
aSignificant at the 5% level.
bSignificant at the 1% level.
cSignificant at the 0.1% level.
Transsexuals who had had surgery were significantly (Table III) more often well or very well adjusted to the aspired gender role, although all UWS patients were already living in the aspired role. Their socioeconomic situation had also improved during this period. Although unemployment was rare in our sample, transsexuals who had surgery tended to be even less frequently unemployed than the transsexuals who had not yet had surgery. In addition, the transsexuals who had surgery coped significantly better financially. Suicide attempts during the follow-up period were a rare occurrence. By contrast with the UWS patients, however, suicide attempts had become significantly (p = 0.040) less frequent among transsexuals who had surgery. As expected, the transsexuals who had surgery were significantly more satisfied with their gender role and also with their sexual experiences (Table III). According to the PIT results, the transsexuals who had surgery were significantly better adjusted psychosocially than the transsexuals who had not yet had surgery but had an unaltered wish for surgery (Fig. 1). The UWS patient group was accordingly still reporting marked difficulties, while the total score of the transsexuals who had surgery indicated only a few difficulties in the psychosocial area. At the time the diagnosis was made the PIT showed no differences between these two groups.
The transsexuals who after an average follow-up of 4.6 years had not had surgery, although it had been offered to them provided they fulfilled the usual requirements, were not a homogeneous group. Our results showed three subgroups differentiated according to their attitude to gender reassignment surgery: transsexuals with an unaltered wish for surgery, the hesitating patients (HP, Group 2), and transsexuals who relinquished their wish for surgery and lived in the initial gender (IG, Group 3).
According to the previous literature (Krohn, 1981; Lundstrom, 1981) there appears to be a further subgroup of transsexuals: those who live in the aspired gender role without having surgery (Group 4). Only one female-to-male transsexual from this subgroup was among our clients. It may be possible to put all transsexuals who have not had surgery into one of these four categories. The transsexuals who had not had surgery described by Meyer and Reter (1979) can largely be categorized as hesitating patients - they were still interested in gender reassignment surgery without however undertaking the appropriate preparatory steps. Five transsexuals had relinquished their wish for surgery and would therefore belong to Group 3 (IG). Six of the 12 genuine transsexuals in the Lundstrom study (1981) had surgery during the follow-up period. Of the six who had not had surgery, three still wanted it (UWS, Group 1), two had given up their wish for sex reassignment (IG, Group 3), and one had committed suicide. McCauley and Erhardt's transsexuals who had not had surgery can also be added to Group 2 and 3. In all the studies, including the present one, the transsexuals who had not had surgery, but who had no present wish for surgery were a minority by comparison with the transsexuals who had surgery and the transsexuals who had not had surgery but wished for it.
The differences between the subgroups with respect to the sociodemographic and psychosocial data were instructive, particularly as far as the hesitating patients were concerned. The distinguishing variables found made the hesitation about gender reassignment surgery understandable: These were wellestablished people who would have had to give up a lot. The variables mentioned were however insufficient to explain the hesitation: Even among transsexuals who had had surgery, there were established transsexuals with children of their own, although there were significantly fewer of them.
Our study showed that the patients who had relinquished their wish for surgery and continued to live or lived again in their initial gender role did not differ significantly from patients with an unaltered wish for surgery. The only difference was that long-standing former partnerships were more common. Reasons for giving up the wish for an operation differed widely and were highly individual: socioeconomic reasons, a highly valued job that could only be carried out in the initial gender role, or development of a meaningful partnership that was only possible in the biological gender role. A few transsexuals could not give any real reason for their decision. All of them uniformly renounced surgery, although the decision had been made with varying degrees of difficulty.
Transsexuals fulfilling the criteria of patients who later hesitated about having surgery could be recognized at the time the diagnosis was made, that is, at the time therapeutic contact was first established. Such patients should be studied particularly carefully because there is much evidence that the aspired gender change has not been psychologically worked through. It is interesting to note that some of the factors that were found by Walinder et al. (1978) to correlate with an unfavorable outcome of sex reassignment surgery can be seen in our groups of hesitating patients, namely, heterosexual experience and a higher average age at the time contact was first made. Other factors however do not fit the description of our hesitating group, such as unstable personality, criminality, and inadequacy, with respect to selfsupport. This group of transsexuals should however still receive intensive counseling with the aim of getting them to make a decision that has been properly thought through in order to avoid an unfavorable outcome of surgery.
As expected, the subgroups developed differently during the follow-up period, when all patients received psychiatric and social counseling. Transsexuals with an unaltered wish for surgery were the only group who made improvements, although in our measurements these were not statistically significant. The improvement with respect to their occupations were one of the conditions for surgery, as this was only to take place if social and mental stabilization had been achieved. The improved relationships towards parents and siblings were more likely due to psychiatric care during the follow-up period. Transsexuals who relinquished their wish for surgery experienced greater sexual satisfaction. This could be interpreted as a sign that they had come to terms with their decision not to have an operation. As expected, there were no changes whatsoever during the follow-up period as far as the hesitating patients were concerned. All transsexuals who had not had surgery reported the same marked difficulties with psychosocial adjustment as at the time the diagnosis was made, although the IG group had fewer difficulties than the others. This was different only for the transsexuals who had surgery. It is thus necessary to find therapeutic ways of helping those transsexuals who do not want to undergo surgery.
When the results of transsexuals who have had surgery are compared with the UWS group, there is distinct evidence of the stabilizing effect of gender reassignment surgery. However this comparison is only of limited value as it concerns two subgroups of a sample, even though the sociodemographic data are comparable (see Table I). The more convincing comparison of the results of three assessments of transsexuals who had surgery (carried out when the diagnosis was made, shortly before surgery, and during follow-up) are described elsewhere (Fahrner et al., 1987), and show not only the positive effect of sex reassignment surgery (for the psychosocial integration of transsexuals) but also the positive effect of a long period of preparation for sex reassignment. There psychiatric and social counseling as well as presurgical living in the aspired gender role is necessary for adequate adjustment. This is in agreement with the findings of Blanchard et al. (1985).
Further investigations should aim at clarifying the motivation of some transsexuals to relinquish or postpone their wish for surgery, as well as trying to find how they can be therapeutically helped to cope with their continuing difficulties with gender identity.
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