Issues in Diagnosis and Treatment of Transsexualism Laura Giat Roberto, Psy.D.1
NOTE: tables have been removed from this document they were so scrambled That they were unreadable.
Transsexualism involves incongruity between anatomy and gender identity in biological normal persons. The literature in this area indicates controversy in diagnosis and treatment. Current guidelines for assessment and treatment selection are critically reviewed. Outcome data suggest that sex reassignment surgery is variably effective and potentially deleterious. Child and adult interventions may be more viable than previously assumed. Recommendations for research include systematic follow-up, longitudinal studies of gender-deviant children, and studies of psychopathology. Until rigorous outcome data are available, return to a conservative position on sex reassignment, using highly exclusive diagnostic guidelines and restrictive selection criteria, is advocated. KEY WORDS: transsexualism; sex reassignment surgery; gender identity disorders. 1Department of Psychiatry and Behavioral Sciences. Eastern Virginia Medical School, Norfolk, Virginia 23501. INTRODUCTION Transsexualism is a condition in which an "anatomy-identity discontinuity" is experienced (Gagnon, 1977). It is the belief, in a biologically normal person, that one belongs to the opposite sex, accompanied by the desire to be and function as an opposite-sexed person (Benjamin, 1966; Stoller, 1968). The term was first used by Cauldwell in 1949, and is sometimes restricted to only those persons who have requested and undergone sex reassignment surgery (Bentler, 1976; Meyer, 1974a). This paper addresses current issues in the diagnosis and treatment of transsexualism. While this disorder is still poorly understood, controversies in management of transsexual patients create the need for a sound conceptual model. Two positions are identifiable regarding the advisability of surgical sex reassignment. One position holds that increased willingness to offer aggressive, radical surgical and hormonal interventions to individuals with desire for reassignment is unwarranted, due to lack of data regarding psychopathology (Kubie and Mackie, 1968; Lothstein, 1977a; Meyer, 1974b; Siomopoulos, 1974). The other position criticizes the practice of labeling transsexual dysphoria as "quasidelusional," "paranoid" or "suicidal" (Baker, 1969; Finney et al., 1974), and suggests that refusal to grant surgery to highly motivated and desperate patients is overdetermined (Green, 1967b; Green et al., 1966b). Preliminary outcome data have intensified the controversy: the American Medical Association's Commission on Human Sexuality (American Medical Association, 1972) suggested that surgery may be the treatment of choice. However, unsatisfactory post-operative outcomes have been reported (Money and Wolff, 1973; Van Putten and Fawzy, 1976). In this paper, it is proposed that returning to an extremely conservative use of sex reassignment surgery is imperative because of the absence of valid defining characteristics, assessment devices, treatment selection, and outcome. Although sex reassignment can offer short-term solutions to immediate management problems with transsexuals, existing outcome data show little efficacy and even deleterious effects in many patients (Meyer and Reter, 1979; Stoller, 1973). There is a very small group of patients with a severe, chronically transposed gender identity and a number of other distinguishing features (Knorr et al., 1968; Randell, 1971). However, more rigorous use of existing assessment procedures is necessary to improve selection criteria. Estimates of prevalence and problems in the diagnostic validity of transsexualism as a syndrome will be presented. Because of the necessity for delivering treatment despite the lack of reliable and valid diagnostic and treatment criteria, existing methods of diagnosis will be critically reviewed along with suggestions for utilization. Specific treatment modalities, which may be more viable than was previously assumed, will be described in terms of goals, procedures, and outcome data. Finally, suggestions for further research are offered. Currently, the clinical definition of adult transsexualism is based on a composite set of characteristics. These include belief that one is a member of the opposite sex (Fisk, 1974), dressing and appearing in the opposite- gender role (Fisk, 1974), perceiving oneself as heterosexual although sexual partners are anatomically identical (Bentler, 1976; Fisk, 1974; Meyer, 1974a), repugnance for one's own genitals (Pauly, 1969) and the wish to transform them (Gagnon, 1977; Meyer, 1974a), history of cross-gender activities (Gagnon, 1977; Stoller, 1968, 1969), and persistent desire for sex conversion surgery (Meyer, 1974a). Table I. REMOVED Observation of elementary school aged children (typically boys) using a number of measurement techniques has suggested some possible antecedents for adult transsexualism (see Table I). However, longitudinal follow-up studies of gender-deviant children have not clarified which characteristics antedate transsexualism as opposed to conflicted homosexuality, transvestism, or no psychological condition. Children are usually brought to professional attention between 8 and 10 years of age (Green, 1974, 1978), although these age trends are currently dropping as treatment facilities are more available. Individuals most frequently seek assistance for transsexualism in late adolescence or early adulthood. Table II. REMOVED PREVALENCE Actual incidence and prevalence of transsexualism is presently unknown. Surveys performed to date in the United States and Europe have yielded estimates for each sex and for sex ratios (see Table II). Researchers consider their data on treated prevalence to be underestimates (Hoenig and Kenna, 1973; Mehl, 1974). The ratio of males to females approximated 3:1 in the early 1970s, but gender identity clinics in locations as disparate as Sweden and Oregon now report ratios approximating 1:1 (Pauly, 1974). Older literature and cross-cultural field studies suggest that cases were predominantly male (e.g., Green, 1966). However, differentiation of transsexualism from transvestism (simple cross-dressing) was not reliable until the late 1800s. Allowances must therefore be made in interpretation of historical case material. Survey methods utilized thus far have several methodological problems: 1. It is assumed that only intolerably stressed transsexuals consult mental health professionals, yielding a very low estimate of true prevalence. 2. Many of the surveys have used mailed questionnaires with an attenuated return rate (76%, according to Walinder, 1967). 3. Diagnostic criteria are unclear and poorly differentiated, yielding a mixed diagnostic group. 4. Surveys often utilize unstructured psychiatric interviews without a "blind" interviewer, introducing research bias (e.g., Hoenig and Kenna, 1973). SEARCH FOR A SYNDROME Research on transsexualism is still at the stage of clinical description. Well-controlled studies of pathognomonic char-acteristics using proper diagnostic validation procedures are lacking. In addition, classification systems based on these criteria have not been studied to determine overlap of measurement and differential utility. Studies that do attempt to test diagnostic criteria using systematic measures (such as sexual history and satisfaction with surgical outcome) include the work of Bentler (1976) and Meyer (1974a). Gender identity disorders are seen essentially as disturbances in the fundamental sense of belonging to one's own biological sex. Transsexualism, the most extreme form, is accompanied by gender dysphoria and the active desire to change one's anatomical sex to match the psychological gender. Changes in core (biological) gender identity (Stoller, 1968), psychological gender identity (Money and Ehrhardt, 1972), gender role, and gender dysphoria (Fisk, 1974; Bentler, 1976) are all involved. According to Meyer (1974a), transsexuals show four common characteristics: 1. Inappropriateness or incapacity in the anatomically determined gender role 2. The belief that improvement will result from role reversal 3. Choice of sexual partners of the same anatomic sex, and inhibition of heterosexual interest 4. Desire for sex reassignment surgery These attributes readily distinguish gender identity disorders from atypical sexual orientations, from sexual dysfunctions, and from variant erotic preferences. For example, variant erotic preferences such as sadism/masochism do not necessarily include incapacity in assigned gender role, desire for role reversal, choice of same-sex partner, or desire for surgery (Benjamin, 1967; Buhrich and McConaghy, 1977a, 1977b; Prince, 1974). Any of these other three disorders may coexist with a gender identity disorder, but they involve separable patterns of psychosexual arousal and interpersonal behavior. Because the attributes common to all transsexuals differentiate them as a group from other sexual disorders, it is tempting to assume that there is a discrete, unitary syndrome. In fact, there is considerable heterogeneity in this population (Bentler, 1976; Fisk, 1974; Gandy, 1974; Meyer, 1974a, 1974b; Pearson, 1974). Patients can be differentiated into approximately four groups (see Table III) on the basis of sexual behavior and reported partner choice. These behavior patterns have been observed predominantly in male sex reassignment applicants and may not be generalizable to females. Further, certain identified groups have been extremely small (e.g., Meyer's "young fetishistic transvestites," N = 3, 1974a), which also creates questionable generalizability. Group 1 ("homosexual") shows a history of late-onset cross-dressing without arousal. It includes homosexual males who claim anxiety, guilt, and stereotyped "feminine" mannerisms. Partner choice has always been for the same anatomic sex. Group 2 ("heterosexual transvestitic") reports a history of cross-dressing that may or may not have led to arousal. This group has shown intermittent or predominantly opposite-sex partner choice. Meyer (1974a) reported what may be an age trend in the fetishistic arousal, but used a cross-sectional sample. Other clinicians have also noted a dropping off of arousal with age in individual patients. Table III. REMOVED Groups 3 and 4 have been viewed as two different populations, "asexual" (or "classical" transsexualism) and "schizoid," but both show minor or absent responsivity to any sexual partner. Individuals are described as emotionally withdrawn and impoverished in interpersonal relationships, although persons labeled as asexual are more likely to report a history of cross-gender striving than those labeled schizoid. Group 5 ("psychotic"), is diagnosed on the basis of overt thought disorder and presence of somatic delusions. It has accounted for as many as 25% of sex reassignment requests (Fisk, 1974; Knorr et al., 1968). Persons diagnosed as schizophrenic express severe gender identity confusion, and certain sex reassignment applicants have shown a degree of somatic preoccupation that reflects impaired reality testing (Knorr et al., 1968; Kubie and Mackie, 1968; Siomopoulos, 1974). These transsexual groups overlap to some extent as presently defined. Bentler (1976), in a comparative study of 42 postoperative male transsexuals, did empirically separate out three primary groups: "homosexual," "asexual," and "heterosexual." These groups yielded data on self-report questionnaire items that differentiated them (in post hoc between-group comparison) on socioeconomic status, average age, education, reasons for surgery, preoperative and postoperative sexual activity, and satisfaction. However, while several groups show clearly differentiable characteristics (e.g., schizophrenia vs. "homosexual" transsexualism), the four nonpsychotic groups (1, 2, 3, and 4) are too idealized to fit most patients (Meyer, 1974a). Gender identity and gender role should be best conceptualized as a cognitive and behavioral continuum in which discrete conditions cannot be separated off with confidence. Degree of cross-gender identity appears to vary clinically between individuals (Stoller, 1973), supporting the notion that strength of primary gender identification may be a clinically significant variable. A number of clinicians have noted that patients with cross-gender identity show accompanying psychopathology. This raises critical questions regarding transsexualism as a discrete category of psychopathology at all, as opposed to a manifestation of an underlying condition such as schizophrenia or paranoid psychosis (Kubie and Mackie, 1968; Siomopoulos, 1974). Few studies have utilized standardized psychometric instruments to investigate psychopathology, so there is little convergence of opinion (Doorbar, 1969; Finney et al., 1974; Paitich, 1974; Pearson, 1974). Two diagnoses given consistently in many sex reassignment applicants, based on MMPI criteria and individual and family interviews, are hysterical personality and paranoid personality (Finney et al., 1974; Pearson, 1974; Stoller, 1968). Finney et al., (1974) found hysterical characteristics to be major or secondary in 67% of cases assessed. Less frequently, sociopathic personality and inadequate or schizoid personality have been diagnosed (Fisk, 1974; Meyer, 1974a; Paitich, 1974; Pearson, 1974). Depression has been reported in several transsexual subgroups (Doorbar, 1969; Finney et al., 1974; Paitich, 1974), but the extent to which the observed depressions were situationally reactive was not assessed. Depression, self-deprecation, "paranoid" behavior, and interpersonal exploitativeness could be the result of social stigma and professional skepticism (Baker, 1969). DIAGNOSTIC INSTRUMENTS AND CLASSIFICATION SYSTEMS Because of the lack of inclusion and exclusion criteria noted above, many assessment instruments are not adequately reliable and valid for differential diagnosis and treatment disposition. For example, transsexualism is often labeled as transvestism because of failure to distinguish between cross- dressing which is fetishistic (causes sexual arousal) and that which does not (Baker, 1969). Poor standardization and validation procedures have further detracted from the utility of these instruments. Diagnostic Instruments The primary assessment instrument is the unstructured interview with patient self-report. A notable exception is the structured interview schedule used by Money and Primrose (1969), which covers four major areas: sexual history, psychosocial history, medical/developmental history, and fantasy/associational content. Significant others are asked to corroborate historical data. Tests of intelligence, visual-motor integration, and gender role are included, as well as neurological, physical, and endocrinological assessment. This interview schedule is more thorough and better documented than those commonly reported. Self-reported symptoms and treatment requests are often weighted too heavily (Friedman et al., 1976; Knorr et al., 1968; Kubie and Mackie, 1968; Meyer, 1974a; Stoller, 1973). Because sex reassignment applicants believe that only genital alteration will resolve their gender dysphoria, they are highly motivated to obtain surgery. Memory is often skewed, or responses distorted, to report only those perceptions and feelings that clearly indicate early-onset cross-gender identity (Knorr et al., 1968). The self-labeled transsexual often has had childhood intervention, and tends to assume the evaluation will be used to convince him/her that the adopted gender identity and role are inappropriate and should be reversed (Fisk, 1974; Knorr et al., 1968). Because of pressure from the professional's gate keeping function and from the patient's persistent desire for surgical sex reassignment, this self- report data resembles the idealized transsexual description reviewed earlier. Independent measurement of critical social, sexual, and psychological variables (Edgerton et al., 1970; Mehl, 1974; Money and Ehrhardt, 1972) is often neglected. Auxiliary assessment techniques will enhance the validity of interview data if used systematically, including the mental status examination, personality instruments, and behavioral assessment. Kubie and Mackie (1968), in an excellent review of diagnostic and treatment issues, have called for construction of specific tests of gender identity and gender role. Behavioral observation in a laboratory setting (Barlow et al., 1973; Rekers et al., 1976), card sort (Barlow et al., 1973), projective tests (Doorbar, 1969), and masculinity/femininity scales such as MMPI Subscale 5 (Paitich, 1974) have all been applied and could be combined to yield an algorithm with predictive value. A rich source of behavioral observation is the "real-life test", originally intended as the initial phase of sex reassignment treatment. During the 1-3 year test, patients live and dress in the opposite-gender role, receive hormonal therapy, and conduct their social and vocational lives accordingly. Observations during this period indicate level of tolerance for emotional distress, degree of social skill in the adopted role, and motivation to undergo permanent sexual reorientation. The test should serve as a confirmation phase of the cross-gender diagnosis (Money and Walker, 1977). For example, Walker (1976) observed that nonfetishistic male transvestites who experience strong feminine identifications found consistent cross-gender behavior intolerable and returned to episodic role-switching. Since a clearcut set of inclusion and exclusion criteria for transsexualism is not available, a "best-fit" decision must be made based on interpersonal and sexual history. Critical questions include the following (Knorr et al., 1968): 1. Rigidity of cross-gender identity 2. Chronicity of cross-gender identity 3. Primacy of cross-gender identity (rule out psychosis) 4. Ability of patient to acceptably enact (socially, vocationally and sexually) the cross-gender role Individuals who fulfill these criteria must further be distinguished from those who wish to appear transsexual. The desire to alter gender role and body outline can represent a maladaptive solution to other, more acute types of emotional distress (Friedman et al., 1976; Kubie and Mackie, 1968). For example, some homosexual males who are unsuccessful in their social communities come to believe that a more feminine body would increase popularity and appear revolted by their genitalia. However, there is a history of genital pleasurability in these cases. In order to avoid false positive judgments, potentially distorted self-report data must be supplemented with multiple reporters and multiple assessment occasions (Walker, 1976). Classification Systems Transsexuals are classified either by using a nosology specific for gender identity (e.g., Fisk, 1974) or by using the standard psychiatric nomenclature (e.g., DSM III; American Psychiatric Association, 1978). The previous discussion of subgroups in transsexualism suggests that as far as possible this population should be distinguished from homosexuality, transvestism, and schizophrenia with gender identity confusion and dysphoria (Benjamin, 1967; Buhrich and McConaghy, 1977b; Freund, 1974; LaTorre, 1976; Ovesey and Person, 1973; Roback et al., 1977). Thus, a rigorous diagnostic procedure should first distinguish between two major classes of psychological disorder: (l) psychosis, and (2) personality disorder-psychosexual subtype (Benjamin, 1954; Calnen, 1975; Kubie and Mackie, 1968; Siomopoulos, 1974). To date, no single classification system has specified criteria for classing symptoms in this manner. Two major systems were developed for use (see Table IV): DSM III (American Psychiatric Association, 1978) and the Stanford University Gender Reorientation Program system (Fisk, 1974). Table IV. REMOVED DSM II (American Psychiatric Association, 1968) offered no subcategory of psychosexual disorders specific for this clinical group. Psychosexual disorders in DSM III do include a subset of gender identity disorders with highly specified defining criteria. However, transsexualism is divided into three subgroups designated by Bentler (1976). While the Stanford University system (Fisk, 1974) also offers a set of subgroups, it contains several that have not been reported elsewhere ("inadequate schizoid" personality; "sociopathic" personality) and omits the "asexual" pattern (Bentler, 1976; Meyer, 1974a). Since the "schizoid" and "asexual" patterns may be quite similar in terms of interpersonal history, sexual functioning, motivations for surgery, and postsurgical outcome, these two subgroups require further comparison. The Stanford system, a two-step procedure, identifies first the presence of severe gender dysphoria and second the subgroup of gender dysphoria. The emphasis on dysphoria as the primary diagnosis represents a broader class of inclusion criteria (Fisk, 1974) when compared with DSM III. Given our current lack of knowledge regarding the history, nature, and course of transsexualism, this broad inclusion criterion may yield an overly high rate of false positive diagnoses. The assessment procedures available for diagnosis must be more rigorously applied. Although we can only speak of a "best-fit" method of diagnosis at present, it is possible that gender dysphoric patients can be validly differentiated into subgroups on the basis of sexual history, chronological appearance of symptoms, extent of cross-gender identification, chronicity, and other sexual and interpersonal variables. The outcome of surgical or psychotherapeutic intervention may differ radically for these different individuals (Bentler, 1976). However, more between group comparisons must be conducted, on a wide range of criterion variables, to clarify the actual uniqueness of these subgroups and their existence as a diagnostic entity. TREATMENT STRATEGIES AND COMPLICATIONS There is considerable disagreement regarding the treatment of choice for transsexualism. Since specific treatment methods are usually not presented in the literature, procedures must be inferred from case descriptions and theoretical statements. Specific treatment outcomes for the three transsexual subgroups have not been researched, with the exception of Bentler's (1976) descriptive study. Further follow-up studies are lacking for most treated transsexuals (Stoller, 1973), so conclusions regarding therapeutic effectiveness are frequently based on speculation. Finally, authors are more likely to publish successful than unsuccessful outcomes (Pauly, 1965; Walinder, 1967). Researchers who believe that transsexualism represents a crystallized gender identity transposition, fixed during a "sensitive period" in childhood, hold little hope for a psychological means to reverse it (Baker, 1969; Benjamin, 1967; Knorr et al., 1968; Money and Gaskin, 1970-1971; Pauly, 1968; Stoller, 1968; Walker, 1976). Those who view transsexualism as a delusional belief reflecting emotional conflict feel that transsexuals may be accessible to psychotherapy (Kubie and Mackie, 1968; Lothstein, 1977a 1977b; Meyer, 1974a; Siomopoulos, 1974). It appears true that reversal cross-gender identity has not been demonstrated in many cases of adult transsexualism (Baker, 1969; Pauly, 1968; Money and Walker, 1977; Walker, 1976; Weitz, 1977), although there have been exceptions. An experimental behavioral program applied in three cases was successful in changing gender identity (Barlow et al., 1973, 1979). A fourth documented case showed evidence of cure by faith healing (Barlow et al., 1977). Most practitioners agree that "the general rule that applies to treatment of the transsexual is that no matter what one does - including nothing - it will be wrong" (Stoller, 1968). Many of these individuals show extreme resistance to psychological intervention, so that effective psychotherapy aimed at gender identity reversal is not considered likely. However, this fact has often precluded even consideration of nonsurgical interventions. Under these conditions, clinicians may view patients as "untreatable" rather than "resistant" persons with long-term patterns of disorder. A second treatment controversy involves management of the strong resistance manifested by transsexual adults toward psychotherapy. They wish to be the opposite sex - to function in it sexually, to be entitled to the legal and social status of that sex, and to eliminate the dysphoria they feel in their anatomical state (Benjamin, 1967). Because nothing less than sex reassignment would cause this dramatic change, gender dysphoric patients are extremely averse to focusing on their dysphoria as a problem (Benjamin, 1967; Knorr et al., 1968; Lothstein, 1977a; Mensh, 1972; Pauly, 1968 Walker, 1976; Weitz, 1977). Viewing psychotherapy as an obstacle to or refusal of surgery, their persistently confused, hostile, urgent, and mistrustful communications are demoralizing to professionals (Baker, 1969; Green, 1967b; Green et al., 1966b; Lothstein, 1977a, 1977b). Establishing a working alliance is difficult if the therapist is unwilling to tolerate this urgency, or if s/he insists on a nonsurgical intervention from the outset. However, some investigators report that an empathic approach, presenting psychotherapy as an opportunity for exploration prior to considering irreversible surgery, often increases motivation (Meyer, 1974a). The major therapeutic approaches include intensive psychoanalytic psychotherapy, supportive psychotherapy, group psychotherapy, behaviorally oriented psychotherapy, and gender reorientation with surgical sex reassignment. These apply to adults and late adolescents only. Early childhood interventions, which appear very viable (Green, 1978), constitute a separate class of procedures. Intensive Psychoanalytic Psychotherapy The goal of treatment is to stabilize the transsexual in a nonoperated state which will allow him/her to adapt to social and vocational living without surgery, or to reverse the cross-gender identity if it is unstable (Green et al., 1966a; Stoller, 1973; Stoller and Rosen, 1959). The assumption is that transsexual ideation is a rigid defense against anxiety-producing gender role incompetence rather than a developmental disturbance in core gender identity (Kirkpatrick and Friedmann, 1976; Knorr et al., 1968). The principle is to reconcile psychological gender with anatomical sex or to make it possible to tolerate the anatomical sex (Benjamin, 1967). Technique is not specific to transsexualism. Interpretation is used to clarify the function of the cross-gender identity as a defense against unacceptable impulses and self- perceptions. Recent psychoanalytic publications regarding treatment of severe personality disorders suggest that a critical factor in establishing a successful working alliance is recognition and use of therapist responses (Lothstein, 1977b). One exploratory study (Lothstein, 1977a) identified specific therapy "stages" in which patient responses (e.g., suspicion and devaluation) appeared to covary with therapist responses (e.g., confusion and rage). Most researchers view analytically oriented psychotherapy as ineffective for altering cross-gender identity (Baker, 1969; Knorr et al., 1968; Stoller, 1968; Weitz, 1977), although other authors report variable outcome (Kirkpatrick and Friedmann, 1976; Lothstein, 1977b). Complications of treatment have been reported. Lothstein (1977a) notes that suicidality or decompensation of functioning may occur because anxiety often increases either at termination or with a decision for surgery. Pauly (1968) states that "transsexual patients have been pushed into psychosis" by attempts to challenge and reverse the cross-gender identity, but without presentation of data. Don (cited in Forester and Swiller, 1972) states that, when challenged in this way, up to 30% of patients developed paranoid ideation in individual psychotherapy and began to experience cognitive disorganization. Motivation for psychotherapy and stress tolerance are, however, difficult to induce while routine sex reassignment surgery is sanctioned by the social and scientific communities. Supportive Psychotherapy The goal of treatment is to help the transsexual cope with alienation, social rejection, and other feelings concomitant with cross-gender identity, with the assumption that psychotherapy usually cannot reverse the condition (Baker, 1969). This approach avoids deliberate initiation either of gender reorientation or of stabilization, focusing instead on increasing skill level in interpersonal relationships and toleration of emotional stress. The assumption made is that necessary social skills did not develop, resulting in formation of inadequate, withdrawing, alienated personalities (Roth, 1974). The patient is encouraged to explore social and sexual experiences and affects surrounding the gender of birth, and motivations for desiring sex change. In an illustrative study of an extremely effeminate male transsexual, frustration tolerance and reality testing increased, and hostile behavior and entitlement decreased. Depression and social anxiety increased, and the patient's gender identity became less rigidly transposed during therapy (Roth, 1974). Group Psychotherapy As in intensive psychoanalytic psychotherapies, the goal of a group approach is to help the patient adjust his/her gender identity without irreversible genital surgery. This psychotherapy has not been widely attempted (Sadoughi et al., 1974). As in supportive approaches, the assumption made is that historically, as a consequence of social isolation, heterosocial skills were not learned, and an inadequate or constricted personality with a same-sex object choice resulted. In the single case report published (Forester and Swiller, 1972), the authors state that an initial attempt at individual psychotherapy apparently failed due to fear of male authority figures. In a group setting the conflict was redefined as anxiety and failure in male role activities, and a decrease in transsexual symptoms occurred. Groups currently offered as part of the transsexual evaluative procedure (Sadoughi et al., 1974) also proceed around informal exchange in an atmosphere that encourages discovery of the patient's patterns of adjustment to psychological stress. Once the group frame of reference is established, some patients have decided against surgery in this context, opting instead for psychotherapy. Behaviorally Oriented Psychotherapy The goal of this intervention is modification of those gender role behaviors that lead the patient and observers to label him/her as gender- inappropriate, and change of those beliefs which s/he attributes back to the gender of birth. The assumption, as in the group and supportive approaches, is that transsexual ideation and behavior represents a set of inappropriate responses learned in the early childhood environment, coupled with failure to incorporate gender-appropriate behavior from peers due to ensuing social isolation (Bates and Bentler, 1973; Bentler, 1976; Green, 1967a; Green et al., 1972b; Mischel, 1970). As these individuals become more and more deviant in contrast to peers, cognitive self-categorizations and labeling processes lead to formation of cross-gender identity (Bentler, 1976). The most successful program to date, utilized in three cases, first attempted to modify effeminate gender role behavior in male transsexuals, and then instituted modeling and behavioral rehearsal of gender-appropriate behavior. Fantasy training was incorporated using shaping, stimulus fading, and reinforcement for heterosexual fantasies and electrical aversion for homosexual fantasies. After this five-stage modification, transsexual attitudes reportedly dropped to near-zero frequency as indicated by card sort (Barlow et al., 1973, 1979). At follow-ups ranging from 1 1/2 to 6 1/2 years, treatment gains were maintained. Earlier behavioral techniques, which used aversive reconditioning alone (Gelder and Marks, 1969; Randell, 1971), were not successful in eliminating gender dysphoria or transsexual attitudes. Treatment complications have not been reported in the literature. The chief disadvantage to this technique at present lies in its intricacy and use of extensive audiovisual aids, which precludes wide usage outside the laboratory. Further, the relationship between gender-related statements endorsed in card sort and gender identity as experienced subjectively and interpersonally has not been established. Gender Reorientation with Surgical Sex Reassignment Surgical sex reassignment involves direct modification of the genitals by removal of external organs and plastic reconstruction of genitals to give the appearance of opposite-sex organs (Benjamin, 1967). Reassignment is incorporated into a five-stage program: 1. Evaluation to determine appropriateness for surgical sex reassignment 2. Exploratory psychotherapy to determine whether the wish for reassignment is mutable and to correct misconceptions regarding surgery 3. Hormone administration for modification of some secondary sex characteristics 4. Real-life test (with hormone maintenance) 5. Sex reassignment surgery Prior to any decision regarding an offer of surgery, attempts are made to identify gender dysphorics for whom surgery would be contraindicated. These groups include patients with psychosis, sociopathy, organic brain syndrome or defective intelligence, severe depression, successful history in marital or parental roles, successful functioning in heterosexual intercourse, gender role behavior which is appropriate now or has been in the past, and transvestitic or homosexual history with reported genital pleasure (Baker and Stoller, 1968; Knorr et al., 1968; Randell, 1971; Stoller, 1973). Tragic postoperative outcomes that have been reported appear to have been due to misdiagnosis or acceptance of patients with severe preoperative emotional disturbance (Golosow and Weitzman, 1969; Hertz et al., Money and Wolff, 1973; Stoller, 1973; Van Putten and Fawzy, 1976). Postsurgical outcome depends on the history of psychological and social functioning, and a stressful or unsuccessful history suggests a similar range of problems after surgery, although not necessarily a continuing gender identity problem (Bentler, 1976; Gagnon, 1977; Knorr et al., 1968; Sturup, 1976). The purpose of exploratory psychotherapy is to confirm the diagnosis of primary transsexualism, to observe the patient's stress tolerance and reality testing, and to convey that surgery is not a gender reassignment but rather a modification of sexual functioning (Benjamin, 1967; Green, 1969; Prince, 1974; Randell, 1971). Because of isolation from peers, idealized stereotypes often have evolved regarding living in the new gender identity (Gagnon, 1977). For example, male transsexuals often imagine that after surgery they will become sexually appealing, adored, and protected housewives who can raise children and care for the household. The reality of social stigma, legal harassment, family withdrawal, relationship failure, and unemployment is in harsh contradiction with such fantasies (Randell, 1971). The "real-life test" requires that patients live in the desired sex vocationally and socially, to prove their ability to function in the reassigned gender (Wojdowski and Tebor, 1976). It is a probationary period of at least 1 year used by most university hospitals in the U.S. (Mehl, 1974; Money and Gaskin, 1970-1971; Money and Walker, 1977; Walker, 1976). The phase includes oral or intramuscular hormone therapy for suppression of existing secondary sex characteristics and maintenance of an opposite-sex phenotype. During this period, a number of incorrectly diagnosed patients have been revealed as false positives (Walker, 1976). Reported failures in reassignment often reveal that a real-life test was not employed (Money and Wolff, 1973). Surgical procedures for altering secondary sex characteristics include augmentation mammaplasty, shaving of laryngeal cartilage, rhinoplasty, testicular implants, bilateral mastectomy, depilation, and bone/cartilage insertion into tubed penile flaps (Edgerton et al., 1970). In males, a four- part procedure is performed: (l) penectomy; (2) castration; (3) labial reconstruction; and (4) formation of an artificial vagina by inversion of penile skin and/or free skin graft (Flowers, 1974). In females, bilateral mastectomy is performed, although there is no satisfactory technique for forming a functional penis. There are many postoperative complications, especially in cases where surgery has been performed in poorly equipped and trained hospitals outside the U.S. Hore et al., (1975), in a sample of eight patients who received vaginoplasty, noted four urethral strictures, four rectovaginal fistulas, two urethral fistulas, one graft-caused infection, two deep vein thromboses, and two cases of vaginal stenosis after vaginal molds had fallen out postoperatively. Five of eight suffered poor postoperative adjustment, three due to the surgical complications and two due to unrealistic expectations that they would feel "fully female." Frequency of surgical complications, problems, and later course of adjustment are not known due to lack of controlled studies. Existing data draw on self-reported satisfaction and stability in sexual and social relationships, ability to maintain employment, police records, psychiatric contacts, marital status, and mental status (Baker, 1969; Benjamin, 1967; Bentler, 1976; Edgerton et al., 1970; Friedman et al., 1976; Meyer and Reter, 1979; Money, 1971; Pauly, 1968; Randell, 1971; Sturup, 1976; Van Putten and Fawzy, 1976). According to these descriptive studies, only a handful of cases from among the hundreds operated have been failures ending in severe depression, psychotic decompensation, or suicide. However, a closer look at studies concluding "generally satisfactory results" reveals significant problems which are skirted. In one follow-up study (Sturup, 1976), 10 male transsexual cases were examined by unstructured interview. At outcome, 6 of 10 patients, "asexual" transsexuals, claimed satisfaction, but their case descriptions reveal significant difficulty in establishing stable relationships, social withdrawal, depression, and in one case a suicide attempt. Three of the 10 patients, "promiscuous homosexual" transsexuals, claimed satisfaction, and after surgery worked as prostitutes. The tenth patient still lives as a male. A recent study of operated versus unoperated transsexuals at Johns Hopkins Hospital improves on earlier research (Meyer and Reter, 1979). Thirty-five patients who had not yet opted for the real-life test were interviewed and followed up analogous to wait-list controls. Comparison of reassigned, late- reassigned, and unoperated patients suggested that surgery did not result in any statistically significant change in legal, socioeconomic, or marital status. Both reassigned and unoperated groups improved slightly over the course of time. This study has, however, been severely criticized by other investigators (e.g., Fleming et al., 1980). Outcomes reported elsewhere have been variable: number of patients who are more dysphoric following surgery, 0- 45%; number of patients lost to follow-up, 12-46% number of patients who show good or excellent social and emotional improvement and satisfaction, 60-100% (Benjamin, 1967; Edgerton et al., 1970; Friedman et al., 1976; Hore et al., 1975; Money, 1971; Pauly, 1965, 1968; Randell, 1969, 1971; Sturup, 1976). Psychological effects of surgery have included psychotic decompensation or sudden reversal to the gender of birth (Childs, 1977; Golosow an Weitzman, 1969; Hertz et al., 1961; Money and Wolff, 1973; Randell, 1969; Benjamin, 1966; Van Putten and Fawzy, 1976). With some patients and/or families litigation has followed sex reassignment because of disappointment with surgical results, even barring postoperative complications (Pauly, 1968). Preliminary data point to increased postoperative dissatisfactions and complications in "asexual" and "homosexual" transsexuals (Bentler, 1976; Meyer, 1974b). In a small group of transsexuals who show early-onset cross- gender identity, social skill in the opposite gender role, and intact judgment and cognitive functioning, surgery has appeared to successfully confirm the internal gender identity (Stoller, 1973). However, it is clear that the lack of diagnostic precision in current practice is responsible for many misassignments to surgery. The evidence for intensive psychoanalytically oriented psychotherapy suggests rare incidence of improvement. Supportive psychotherapy, individually or in groups, has not been widely reported in the literature to date. A proposed group technique (Forester and Swiller, 1972) resulted in one successfully treated case, although the patient presented with gender- appropriate mannerisms and physical attributes. Recent behavior techniques relying on modeling with feedback of appropriate gender role behaviors, use of verbal praise, shaping of heterosexual fantasies with stimulus fading, and aversive conditioning for homosexual fantasy resulted in three successful cases (Barlow et al., 1973, 1979). Such a treatment program appears quite promising but has remained underutilized, possibly due to the extensive nature of the laboratory procedures. Gender reorientation and sex reassignment surgery has presented a radical intervention which, for patients willing to undergo the multiple phases, resolves many of the initial complaints. However, severe treatment-related disorders have resulted (psychotic decompensation, maladaptive interpersonal behavior, severe depression or paranoid ideation, and suicide). In a small group, treatment has resulted in a more successful adaptation socially, vocationally, and sexually in the new gender role. However, the expense, pain, and psychological trauma clearly suggest that less intrusive techniques, such as behavioral interventions or trials of intensive psychotherapy for severe personality disorder, are indicated as an initial effort. Childhood Interventions Unlike the case with late adolescents and adults, gender reorientation can be accomplished for children who show evidence of gender-inappropriate behavior and cross-gender identity (see Table I). If intervention is begun in early childhood, it is possible that cross-gender identifications can be modified before the effects of the developmental "critical period" (ages 3-5) are immutably consolidated (Baker, 1969; Money et al., 1957; Stoller, 1967, 1968). Because gender identity formation is more malleable in childhood, it has been proposed that therapeutic intervention be focused on this age group (Green, 1978; Green and Fuller, 1973). The goal of treatment is to reduce immediate psychological distress and social ostracism, and thus potentially to prevent adult sexual or gender identity disturbances (Green, 1974, 1978; Wolfe, 1979). Most adult transsexuals report an early cross-gender identity (Benjamin, 1966; Green, 1974; Stoller, 1968). A study of 500 adult transvestites revealed that half began cross-dressing before puberty (Prince and Bentler, 1972). Homosexual males often report effeminate behavior in grade school (Zuger, 1966). In three follow-up studies of previously diagnosed effeminate boys totaling 26 subjects, 14 were judged heterosexual (Green, 1974; Lebovitz, 1972; Zuger, 1966). However, although gender-inappropriate behavior in childhood may not represent a marker for adult transsexualism, a case can be made for intervention whether or not it will serve as prevention. There is evidence that, in boys, cross-gender fantasies and desires for sex change produce discomfort whether or not the social environment approves, and whether or not a long-term gender identity problem is involved. Families also become concerned regarding such children's peer difficulties (Green, 1974,1978; Rekers et al., 1977). Major treatment approaches for children involve both individually based child intervention and group-based parent intervention (Green, 1974, 1978; Green and Fuller, 1973; Rekers et al., 1976). With the child, psychotherapy focuses first on sex education. The positive aspects of the child's own gender are emphasized, and his/her reasons for desiring the role and activities of the opposite gender are discussed. Stereotypes concerning activities allowable to each gender are corrected. With boys, a male therapist is utilized to encourage male identification; few girls are referred for treatment. If possible, same-sex playmates who are neither stigmatized nor role stereotyped, are found in the community to strengthen the conflicted gender identity. A play therapy group is added to further strengthen the gender identity. With the parents, intervention follows two tracks: education in behavior modification to reinforce gender-appropriate behavior and extinguish inappropriate behavior; and use of a couples group and parent group. In fatherless households, male relatives or "big brothers" are found (Green, 1967a). In parent groups, mutual adult supportiveness and peer supervision are used to monitor consistency of child-rearing practices and parental relationship problems with the child. Preliminary outcome data indicate that children with evidence of atypical gender identity do respond to intervention by shifting toward the typical range of gender role behavior (Green et al., 1972b; Rekers and Lovaas, 1974; Rekers et al., 1974, 1976; Rekers and Varni, 1977a, 1977b). Parent narratives and home behavioral ratings prior to and during therapy indicate that change occurs on a variety of dimensions: less cross-dressing; less "feminine" mimicry; less opposite-gender role taking; fewer verbalizations of dysphoria; and closer father-son relationships. However, the relationships between gender role behavior, internal gender identity, and later sexual object choice remain unclear (Green and Fuller, 1973; Green, 1978; Wolfe, 1979). One caveat concerning childhood intervention, however, stems from the fact that it does appear effective in modifying cross-gender behavior. While treatment seems indicated because of the children's distress and social isolation, the methods used involve reinforcement for stereotyped gender role behaviors. This provides an extremely limited perspective on masculinity/femininity in our culture and perpetuates a value system based on gender-specific socialization (Gagnon, 1977; Wolfe, 1979). A second danger is that, under parent and peer pressure, children may try voluntarily to suppress "offensive" behaviors rather than internalizing a change in gender orientation. A further possibility is that behavior modification that punishes gender-deviant behavior and rewards gender-normative behavior can also train out desirable traits that are personality, not gender, characteristics. The better alternative would be intervention that would also help to modify the gender-stereotyped school and community environments where stigmatization occurs. SUMMARY AND RECOMMENDATIONS Transsexualism has captured historical and current scientific interest because it is so severe a disorder, resistant to change in adulthood. First treated with genital reconstruction by Hamburger and colleagues in 1953, in recent years requests for relief from gender dysphoria have become more common (Hamburger, 1953; Hamburger et al., 1953). Resulting experimentation with treatment of transsexuals has led to controversy in theory and practice between researchers who believe that the condition is accessible to psychotherapy (Kirkpatrick and Friedmann, 1976; Kubie and Mackie, 1968; Lothstein, 1977a, 1977b) and those who believe that only gender reassignment is possible (Baker, 1969; Benjamin, 1966, 1967; Money and Gaskin, 1970-1971; Pauly, 1968; Walker, 1976). Discovery in the last decade of transsexual subgroups (Bentler, 1976; Meyer, 1974a) has led to speculation that transsexualism is not a homogeneous syndrome but reflects a condition that may result from multiple psychosocial and sexual histories, motivations, self-concepts, and stress-coping strategies (Bentler, 1976; Knorr et al., 1968; Lothstein, 1977a). Follow-up of patients who have undergone surgery since 1953 has indicated that outcome is variable depending on whether preoperative adjustment was primarily "heterosexual," "homosexual," or "asexual" (Bentler, 1976), and a number of transsexuals with accompanying psychopathology have experienced psychotic decompensation, reversal of the cross-gender identity, or suicidal depression after surgery (Van Putten and Fawzy, 1976). Study of these cases has suggested that diagnostic criteria have not been adequately specified and assessment procedures have not been adequately standardized or rigorously applied save for a few exceptions (Money and Primrose, 1969). Because outcome and follow-up studies of different treatment approaches are lacking (Stoller, 1973; Van Putten and Fawzy, 1976), it is unclear which is the treatment of choice for which transsexual subgroup. Only behavioral interventions have been systematized, well documented, and replicated to date. Gender reorientation with surgical sex reassignment has been reported to improve self-concept, social/vocational functioning, and stress tolerance (Benjamin, 1967; Friedman et al., 1976; Money, 1971; Pauly, 1968; Randell, 1971; Satterfield, 1981). All surveys have claimed variability of outcome, and severe failures occur (Money and Wolff, 1973; Randell, 1971; Sturup, 1976; Van Putten and Fawzy, 1976). Child intervention for gender dysphoria and atypical behaviors appears quite effective and may be of use as a preventive tool. Given these preliminary indications that adult transsexualism takes different forms and is mutable, the following recommendations are suggested: 1. A concentrated effort should be made to gather follow-up data for specific transsexual subgroups, using behavioral checklists, measures of cross-gender identification, sexual fantasy material, and measures of personality organization. Follow-up data should be gathered at initial assessment, early in psychotherapy, at half-year intervals, and at 1-, 3-, and 5-year intervals if possible in adults, assessing changes in social, vocational and psychological functioning for use in establishing a current treatment of choice. 2. Longitudinal studies of gender-deviant children should be instituted to establish more clearly the relationship between childhood gender role and adult gender identity and sexual partner choice. Comparable follow-up for treated children should be conducted using standardized assessment instruments and intervals to yield further data on the utility of primary prevention. 3. Transsexual subgroups must be examined in terms of associated personality organization and psychosocial and sexual history. Standardized psychological assessment would clarify the presence and nature of accompanying psychopathology. 4. 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