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.
INTRODUCTION
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.
METHOD
Sample
The follow-up study included all patients who (during the period from
January 1970 to December 31, 1980) were examined by one of the authors in a
Psychiatric Outpatient Clinic and diagnosed according to the diagnostic
criteria of the DSM III (American Psychiatric Association, 1980) as
transsexuals. Particular care was taken to differentiate between
transsexualism, transvestitism, and homosexuality, using the criteria of
Lundstrom et al. (1984) in addition to the DSM-III criteria. According to
these criteria a total of 80 patients were selected from the case histories.
Of the 80 patients, 59 (74%) were interviewed (The data of one of them could
not be used.); 4 patients (5%) refused to take part in the investigation, with
4 patients (5%) the interview could not take place for organizational reasons,
and 3 patients (4%) had died. The addresses of 10 patients (13%) could not be
ascertained. The average duration of the follow-up period from time of
diagnosis was 5.5 years for the total sample. Of the 58 transsexuals
interviewed, 37 were male-to-female transsexuals and 21 female-to-male
transsexuals. Further biographical details of the sample are contained in
Table I.
Table I. Description of Sample
Total follow-up sample
of transsexuals (N = 58)
Variable M-to-F (n = 37) F-to-M (n = 21)
Age in years (x) 24.9 32.1
(SD 8.2) (SD 6.4)
Status
Single 25 (68%) 16 (76%)
Married 4 (11%) 4 (19%)
Divorced 8 (22%) 1 (5%)
No. of transsexuals
With children of their own 7 (20%) 1 (5%)
Without children of their own 28 (80%) 19 (95%)
Occupation
Salaried employee 17 (46%) 5 (24%)
Civil servant 4 (11%) 2 (10%)
Manual occupation 9 (24%) 10 (48%)
Self-employed 4 (11%) 2 (10%)
Student 3 (8%) 2 (10%)
At the time when the diagnosis was made, both groups differed significantly
with respect to social integration, as defined by the PIT rating scale (see
Procedure). Proportionately more female-to-male transsexuals were socially
integrated (Wilcoxon: Z = 2.6947, p < 0.007, two-tailed, 16 female-to-male, 30
male-to-female). Other pre-follow-up differences could not be statistically
compared due to considerable gaps in the data. Two thirds of the female-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).
Procedure
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.
RESULTS
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 ² 0.05) and to derive sexual
satisfaction from them (p ² 0.05) than are male-to-female transsexuals. All
12 partners of the female-to-male transsexuals belonged to the same biological
sex, whereas only 6 of 10 partners of the male-to-female transsexuals belonged
to the same biological sex. According to the statements made by the 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 ² 0.06) and to maintain close contact
with their families (p ² 0.10) than were male-to-female transsexuals. Another
trend, attempted suicide, was found to occur more often among male-to-female
than female-to-male transsexuals (p ² 0.09). All except one of the attempted
suicides took place before sex reassignment surgery. In their psychosocial
integration, as measured by the PIT, there were no differences between the two
groups at the time of follow-up.
Differences Between Male-to-Female and Female-to-Male Transsexuals Who Had
Had Surgery at the Time of the Follow-Up Assessment
Some of the differences between male-to-female and female-to-male
transsexuals could have been due to the greater difficulties of male-to-female
transsexuals before gender reassignment surgery. If so, they should have
disappeared after surgery; differences with respect to social relationships
however continued to exist. More female-to-male transsexuals who had had
surgery had steady sexual partners (11 of 11 at the time of follow-up) than
male-to-female transsexuals (6 of 14) who had surgery (x2 = 6.80, p < 0.009),
and the partnerships were of significantly longer duration (p < 0.014,
Wilcoxon). All their partners were informed about their transsexuality, by
contrast with 60(%of the male-to-female transsexuals. There were no longer
any differences with respect to evaluation of their sex life: both groups
reported satisfactory sex. When psychosocial integration was evaluated (PIT)
there were no differences between the male-to-female and female-to-male
transsexuals who had undergone surgery.
DISCUSSION
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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