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 
   KEY WORDS: transsexualism; sex reassignment surgery; gender identity 
   1Department of Psychiatry and Behavioral Sciences.  Eastern Virginia 
Medical School, Norfolk, Virginia 23501.  
   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
   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). 
   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 
   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 
   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). 
   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 
   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., 
   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. 
   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 
   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 
   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 
   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. 
   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 
   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 
   4.  Selection criteria for surgical sex reassignment must be refined in 
light of findings that some transsexuals with severe psychopathology 
deteriorate further after surgery.  Reassignment procedures must be rigorously 
denied whenever surgery is considered to present this risk. 
   5.  Return to an extremely conservative position regarding when to grant 
sex reassignment surgery is advocated.  Surgery should be performed only at 
hospitals under the auspices of well planned gender identity research 
projects, and no surgery should be performed without a detailed plan of 
   6.  Diagnostic instruments specifically intended for the measurement of 
gender identity and gender role must be developed and validated against other 
currently existing measurement procedures. 
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