Male-to-Female and Female-to-Male 
   Transsexuals: A Comparison1 
   G. Kockott, M.D.2,3 and E.-M. Fahrner, Ph.D.2 

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