From FEMINET, Felton CA 408-335-4387 or 408-335-7888
The Mid-Life Male Sex-Change Applicant:
A Multiclinic Survey
Howard B. Roback, Ph.D.,1
Elyse Schwartz Felleman, M.A.,1 and
Stephen I. Abramowitz, Ph.D.2
Directors of coordinators of a cross-section of North American Gender
Identity Clinics provided descriptive information on 1,637 sex-change
applicants and psychosocial, psychosexual, and psychiatric data on 21 middle-
aged male candidates. To determine the age relatedness of the findings, the
mid-life male candidates were then compared on selected characteristics with a
random sample of younger biological males seeking sexual reassignment at the
Vanderbilt Gender Identity Clinic. The results are consistent with previous
findings highlighting the factors at mid-life that intensify the male
transsexual's desire for sexual transformation. Viewing the aging gender
dysphoria patient's surgical request from a developmental perspective promotes
appreciation of his predicament and informed consideration of his treatment
options.
KEY WORDS: transsexualism; transvestism; gender; sex role; life cycle.
The three authors contributed equally to the research.
1Department of Psychiatry, Vanderbilt University School of Medicine,
Nashville, Tennessee 37232.
2Department of Psychiatry, University of California, Davis School of
Medicine, Davis, California 95616.
INTRODUCTION
For many, the middle years are a time of questioning, regret, and change
(Gordon, 1978). The "mid-life crisis" refers to the intense develop mental
conflicts often activated during the years of transition from young to middle
adulthood or from middle to older adulthood. Although the personal
reevaluation that often occurs during these periods is known to precipitate
revisions in the value system and career perspective as well as the family
structure, the "crisis" is often dramatically portrayed in the popular media
by the middle-aged husband who leaves his wife and grown children for a
younger woman who serves to revitalize his flagging masculinity. There is,
however, a lesser known scenario in which the middle-aged married man who has
grown increasingly alienated from his masculine and paternal roles flees his
family and for the first time seeks out sexual reassignment surgery. Despite
the far-reaching personal consequences of such a decision, its social and
clinical significance and its relevance to the burgeoning work on adult male
development, a literature search turned up only two articles fully devoted to
this topic. Steiner et al. (1976) delivered a paper at the Canadian
Psychiatric Association convention in 1976, and Lothstein (1979) published the
lone manuscript in the U. S. literature in 1979.
Steiner and her colleagues (1976) evaluated 21 anatomical male sex-change
candidates between the ages of 40 and 65. Seventeen had been or still were
legally married. The sexual-reassignment applicants were characterized by a
history of crossdressing and a current depression, manifested in sleep
disturbance, anorexia, and somatic preoccupation. Steiner et al. noted the
marked similarity of her patients to the aging transvestite group of sex-
change applicants described by Meyer (1974). On the basis of the depressive
symptomatology and the transvestic nature of their patients, the investigators
encouraged marital or supportive individual therapy and antidepressant
medication when necessary, rather than reassignment surgery. The patients'
desire to become women was seen as "an escape from the pressure of their
middle-age crisis associated with the difficulties of maintaining a
transvestic existence" (Steiner et al., p. 14). Their conclusion appears to
be compatible with the observations of others. Lothstein (1979) sees "little
chance that the aging patient will be gratified by admiring looks and glances
when crossdressing or masquerading as a man or woman [and] greater likelihood
of public ridicule and harassment" (p. 434). Meyer (1974) has commented that
when an "already shaky masculine identity is further threatened by physical
involution and sociocultural devaluation, [the transsexual may] seek refuge in
being passive and female" (p. 534).
Lothstein (1979) has provided a clinical description of 10 sex-change
applicants ranging from 45 to 63 years of age. Each of the eight biological
males and one of the two females had been married at least once. Consistent
with Steiner's (Steiner et al., 1976) Toronto group, developmental crises,
depression, long-standing episodic and secretive crossdressing, and a
similarity to Meyer's (1974) aging transvestites were noted among this
Cleveland sample. Lothstein postulated the possible operation of such dynamic
factors as the seeking of immortality and a last chance to resolve lifelong
gender conflicts. He also identified some apparent precipitants to applying
for sex-change surgery, such as a recent loss in a relationship, job, or
financial sphere. Lothstein favors the use of individual, conjoint, or group
therapy in conjunction with steroids and psychotropic medication over surgical
procedures. However, he does not preclude sex-change surgery for some mid-
life applicants and notes the apparent success with Jan Morris and Renee
Richards.
The present research represents an effort to generalize the tentative
inferences about middle-adult sex-change applicants to a more representative
national sample. In the first phase of this study, 28 gender identity clinics
in North America were surveyed to develop a demographic profile of sex-change
applicants and a more detailed personal and clinical profile of middle-aged
applicants in particular. In the second phase, these mid-life sex-change
candidates were compared on a number of dimensions with a sample of younger
transsexuals who requested sexual reassignment surgery at the Vanderbilt
Gender Identity Clinic.
METHOD
Instruments and Procedure
A two-part questionnaire was developed and sent to directors or
coordinators of 28 gender identity clinics listed by the Janus Foundation. In
the first section, respondents were asked to provide demographic information,
including the age, biological sex, and race of persons presenting and accepted
for sexual reassignment surgery. In the second section, respondents were
requested to review the clinical files of their last three mid-life sex-change
cases and provide detailed personal data about them. Information was sought
about the mid-life applicant's familial, educational, sexual, and marital
history, current occupational status, and recent losses. Respondents were
also asked to give their behavioral observations and subjective impressions
about each case, reasons the applicant appeared to be seeking sexual
reassignment surgery at that time, disposition and follow-up data, and all
psychiatric diagnoses that applied.
Respondents and Mid-Life Cases
Seven gender identity clinic heads completed both parts of the
questionnaire. Two additional respondents completed only the first part, and
one individual completed only the second part. This represented a clinic
return rate of 32% for the demographic survey and 29% for the specific data on
mid-life sex-change applicants. Participating clinics appeared to be
reasonably representative of those contacted in terms of size and geographical
region. Four respondents were physicians, four were clinical psychologists,
and one was a registered nurse.
Although each of the eight center chiefs who completed the second part of
the questionnaire did so for three white sex-change patients, three of these
24 cases were female-to-male applicants. These cases were deleted from the
analysis to preserve uniformity with respect to the applicant's anatomical
sex, resulting in a sample of 21 white, mid-life, male-to-female candidates
for sexual reassignment surgery.
Younger Sex-Change Applicants
Twenty-one white applicants for sexual reassignment surgery aged 39 or
under were sampled randomly from the Vanderbilt Gender Identity Clinic. By
comparing the demographic, personal, and clinical data on mid-life sex-change
applicants with corresponding data obtained from the younger Vanderbilt
sample, inferences about older sex-change applicants per se could be
extricated from those that apply to sexual-reassignment patients regardless of
their stage in the life cycle.
RESULTS AND DISCUSSION
The national demographic data concerning requests and approvals for sexual
reassignment are reported first. Consideration of the more detailed
information gathered on the 21 mid-life male applicants follows. The section
concludes with an examination of the differences between the national mid-life
sample and the younger Vanderbilt controls.
Demographic Profile of National Sample
Demographic information with regard to persons asking and accepted for sex-
change surgery is shown in Table 1. As can be seen from examination of the
data, fully 90% of the individuals seeking sexual reassignment surgery at the
nine responding gender identity clinics were under 40 years of age, and only
10% were 40 or over. In addition, 83% of the applicants were biological
males. The disproportionate number of younger sex-change applicants could
reflect that many transsexuals have come to terms with their gender dysphoria
by mid-life, relinquished hope of ever becoming female, or simply be less
informed about the surgical alternative. The overrepresentation of male
candidates probably reflects either the growing awareness that the male-to-
female procedure is less complex and generally more successful than
construction of the penis or that the severe gender dysphoria that prompts the
seeking of sexual reassignment is more intense in males than in females.
Table I. Requests and Approvals for Sexual Reassignment Surgery at Nine
Gender Identity Clinics
Applicants under 39 years Applicants over 40 years
Requests Approvals Rate Requests Approvals
Rate
Males 1224 185 15.1%a,b 132 35 26.5%a
Females 249 55 21.1%b 32 7 21.9%
ax2 = 11.34, df = 1, p < 0.001.
bx2 = 7.38, df = 1, P < 0.01.
Of all the applicants, 17% were approved for surgery. Rate of approval was
not, however, independent of the patient's age and sex. Younger male-to-
female candidates were less likely to be accepted for surgery overall,
significantly so in relation to their middle-aged counter parts x2 = 11.34, df
= 1, p < 0.001) and to younger female-to-male candidates (x2 = 7.38, df = 1, p
< 0.01). Since the male-to-female transformation is thought to be less
complicated than the female-to-male procedure and older patients typically
exhibit more surgically disqualifying characteristics than younger patients,
neither finding supports the conventional wisdom. Perhaps many of the large
number of male applicants, knowledgeable about the relative effectiveness of
their reassignment procedure, were judged to have opted for the surgical
alternative before thoroughly considering other ways to resolve their gender
dysphoria. Since many female transsexuals are undoubtedly aware of the
delicacy of their reassignment procedure, they conceivably do not apply for
surgery until having undergone such a weeding-out process.
Of the 1,637 transsexuals requesting sexual reassignment, 164, or 10%, were
black. As compared with 74% of the white patients, 84% of the black patients
were males under 40 years of age. The overall surgical acceptance rate for
black applicants was 23%, largely reflecting the higher approval rate of those
under-40 males (24%) as compared with their white counterparts (14%). The
reason for the unexpectedly higher surgical approval rate among younger black
males is unclear, although it is tempting to invoke countertransference
phenomena. Assuming that most, if not all, of the responding clinicians were
white, empathic overidentification could well contribute to understanding the
predicament of the black applicant as especially likely to be due to his
"environment" (i.e., a woman "trapped" in a man's body) and thus to regard him
as appropriate for surgical modification. Of course, sadistic impulses on the
part of the clinicians could also explain the overrepresentation of blacks
among those approved for sexual reassignment surgery.
Profile of Mid-Life Applicants
The clinic chiefs conducted intensive case reviews of 21 male-to-female
mid-life sex-change applicants. Of the 19 candidates for whom such data were
available, four had secured a postgraduate degree, four had a bachelor's
degree, two had had some college, four had a high school diploma, and five had
not completed high school. Of 20 mid-life transsexuals, 12 were employed, 1
was retired, and 7 were unemployed. 10 described their occupation as
professional, and 6 as skilled and sales oriented; 1 was disabled, none
reported unskilled work, and information was unavailable on the remaining 4.
Thus, despite wide variation within the subsample, many of the transsexuals
were well-educated and gainfully employed at the time of applying for the
surgery.
Of the male transsexuals, 9 were currently married, with 7 living with
their spouses and 2 separated; 7 middle-aged patients were divorced, and only
5 had never married. For the nine married patients, the mean relationship
duration was 22.7 years (SD = 12.6). For the seven divorced patients, the
mean length of the longest previous marriage was 10.6 years (SD = 7.1).
Twelve of the patients had at least one child. At the time of their
application for sex-change surgery, the mean age of their children was 20.1
years (SD = 8.9). Thus, consistent with previous findings (Lothstein, 1979;
Meyer, 1974; Steiner et al., 1976), most of the sex-change seekers had married
at least once, demonstrated a capacity to maintain a stable relationship, and
sired children.
In only four cases could the responding clinician comment on the spouse's
personality functioning. Two were described as "seemingly normal." Another
partner's extreme dependency on the applicant was noted, and a fourth's
controlling interpersonal hostility was highlighted. One of the two normal
spouses was considered supportive of her husband's desire to be sexually
transformed. She may resemble some of the wives of transvestites whom Stoller
(1967) described as "succorers." Four spouses were categorically negative
about the idea. Another, the "hostile" woman, did not want a lesbian
relationship with a reassigned husband and thus gave what at best amounted to
a very mixed message. It was not clear whether the dependent woman whom the
respondent characterized as having a symbiotic relationship with the applicant
was even aware of his surgical intent. Moreover, only four of the patients
were thought likely to remain with their current partners postsurgically.
Coupled with the minimal level of support most applicants received for their
decision to seek sexual reassignment, this finding supports the observation of
Steiner et al. that their marriages are often severely stressed.
The mid-life applicants reported different reasons for seeking sexual
reassignment surgery at the time they did, and some had multiple reasons for
doing so. In six instances, gender conflicts had become intolerable, and in
six others surgery was thought likely to help ameliorate their personal
distress in some way that was left unclear. Three individuals felt that
advancing years made it a "now or never" decision, and two each noted having
the desire to be loved and admired as an attractive female and to receive
social acceptance. The salience of these three categories recalls the social
devaluation cited by Meyer's (1974) transvestites and the "regressive yearning
to be loved and protected as a woman" observed among Golosow and Weitzman's
(1969) transsexuals. Two others now had the money to pay for the operation.
One person mentioned having previously been unaware of sex-change surgery,
another felt that his partner now approved of it, and a third was dissatisfied
with his transvestic existence.
Critical life events often occurred from 6 months to a year prior to the
request for sexual transformation. Termination of a meaningful relationship
was mentioned twice, and surgical removal of a body part, loss of a job, and
release from prison (and consequent loss of subcultural supports) were each
mentioned once. Four patients were preoccupied with physical deterioration.
The daughters of two mid-life patients had begun to menstruate, perhaps
evoking envy and concern over waning femininity. These data reinforce
Lothstein's (1979) observation that some type of loss often precipitates the
decision to seek sexual reassignment surgery.
When respondents were encouraged to give their clinical impressions of the
applicant's reasons for changing his biological sex, unrealistic, vague, or
delusional beliefs were noted six times, and a desperate attempt to cope with
aging and dying fantasies was mentioned five times. The desire to have the
surgical procedure was seen as a means of resolving intensified gender
difficulties in four instances, as a "last-chance" decision compelled by
advancing age in three cases, and as a way of coping with aggressive impulses
in three others. No other impression was elicited more than once. Several of
these assessments suggest that the desire of some mid-life male transsexuals
to become a woman represents an attempt to compensate for bodily
deterioration, death anxiety, and other concomitants of aging. Once again,
loss is implicated as a motivating factor.
Respondents applied 54 diagnoses to the 21 mid-life applicants, or more
than two per patient. In order of frequency, the psychosexual diagnoses were
transvestism with transsexual features (10), transsexualism (7), asexuality
(7), and transvestism (6). Sex-change surgery may thus be seen as a last
chance to revive sexuality. Other diagnostic impressions were character
disorder (5), characterologic depression (4), conflicted homosexuality (3),
schizophrenia (3), borderline personality (3), neuroticism (3), alcoholism
(2), and psychoticism other than schizophrenia (1). Although Steiner et al.
(1976) reported no psychoticism among their sample, the rate of psychoticism
among Lothstein's (1979) males (25%) was similar to our own (19%). All of the
Toronto patients were believed to manifest signs of involutional depression,
while 75% of the male patients in the Cleveland sample were thought to suffer
from some type of personality disorder dominated by schizoid-obsessive
features.
All but one mid-life candidate reported previous psychiatric outpatient
contact. Six (29%) had been hospitalized, and five (24%) had attempted
suicide, as compared with Lothstein's (1979) figures of 50% and 70% and his
characterization of some as "manipulatively suicidal." The high incidence of
social isolation (11) among our sample is likewise noteworthy and consistent
with other observations of the mid-life sex change applicant. One individual
had been in prison for homicide, an impulse in older sexual reassignment
applicants about which Lothstein (1979) and Meyer (1974) warned. Our
candidates were also described by respondents as self-destructive (3),
dependent (3), expressing aggressive impulses (2), and obese (2). The extent
to which the foregoing evidence of psychological difficulties among our mid-
life sex-change applicants can be attributed to underlying psychopathology as
opposed to social discrimination or even to gender dysphoria is, of course,
unclear. Nevertheless, pending the application of normal, psychiatric, and
psychosexual control groups, it would appear reasonable to infer that the
lives of these patients are characterized by much despair and turmoil.
Responding clinicians also rated the masculine versus feminine appearance
and the attractiveness of 18 of the middle-aged transsexuals. Thirteen were
judged to be relatively masculine, and five were judged to be relatively
feminine. The mean attractiveness rating along a five-point bipolar scale was
2.8 (SD = 1.3). Two individuals were rated as attractive three as slightly
attractive, six as average-looking, three as slightly unattractive, and four
as unattractive. Two of the latter, who were quite masculine in appearance,
presented with the unrealistic goal that sexual reassignment would afford them
the opportunity to be transformed into an extremely attractive and feminine
woman. In terms of motivational implications, these data invoke the notion of
flight from the aggressivity implicit in the masculine role. They also are
consistent with Lothstein's (1979) suggestion that some mid-life male
applicants view sexual reassignment as a means of achieving immortality in the
form of the female's youthful appearance and longevity.
With regard to case disposition, four of the mid-life patients were
approved for surgery, and a fifth was accepted into a probationary program.
Several individuals were rejected for the probationary program but were
recommended for individual psychotherapy (6), group therapy (2), estrogen
therapy and a support group (1), a trial on Provera (1), or told that it was
"okay to crossdress" (1). Among the psychotherapeutic aims reported were
helping the patient to accept his heterosexual transvestism or to ameliorate
his underlying depression. Four individuals were rejected without an
alternative disposition and one was recommended for further evaluation. Since
both Steiner et al. (1976) and Lothstein (1979) reported some success with
marital therapy, it is noteworthy that none of the nine married or separated
couples in the national mid-life sample were recommended for this treatment
alternative.
Three of the four older applicants approved for surgery had undergone the
sex-change procedure by the time of the study. The follow-up interval ranged
from "recently" to 4 years. Two persons were evaluated as very satisfied with
their decision because they no longer had to struggle with alternating between
masculine and feminine roles. The third person had made several postsurgical
suicide attempts, including the slashing of "her" throat, although her
condition had apparently stabilized. Another poor outcome in an older sexual
reassignment patient has been discussed by Van Putten and Fawzy (1976).
To identify any systematic differences between those mid-life applicants
who were and those who were not accepted for surgery, the case data of four
middle-aged applicants who were accepted were compared with those of three
fellow applicants who were not. On the basis of this impressionistic
comparison, the "good" mid-life candidates were viewed as more likely to be
transsexual than transvestic by whatever criterion was used at the center.
The "better" mid-life sex-change candidates were also more likely to have
started crossdressing earlier in childhood, to have had their first
heterosexual experience in early adulthood rather than during adolescence, to
have received some college education, to have demonstrated some stability, at
least in terms of longevity on the job or in the marital relationship, and to
have manifested less overt, long-standing psychopathology.
Mid-Life Versus Younger Applicants
Respondents were also asked to note any differences in family background,
sexual history, and psychopathology they observed between their older and
younger male sex-change applicants. Briefly, they tended to perceive few
diagnostic differences, although several clinicians believed that the older
sex-change applicants tended to be more depressed and schizoid-obsessive.
Respondents experienced middle-aged applicants as more likely to be married
and to have fathered children, to have prominent death anxiety, to present
more as transvestites, to not look very attractive or feminine, to seem less
of the "typical hysterical stereotype," and to limit their impulsivity to
crossdressing.
To determine more definitively whether the characteristics of the mid-life
applicants noted above are in fact age related, comparisons along a number of
dimensions were made between the national subsample of middle-aged male sex-
change candidates and a random sample of under-40 male candidates who
presented at the Vanderbilt Gender Identity Clinic. The mean ages of the mid-
life transsexuals and of the younger transsexuals were 51.7 years (SD = 10.0)
and 24.4 years (SD = 4.6), respectively.
As summarized in Table II, four t tests were performed on continuous
dependent variables, and three x2 analyses were performed on dichotomous
variables. Two of the t tests yielded significance between-group differences
and a third revealed a trend. The national mid-life sex-change applicants
were older than their younger Vanderbilt counterparts both when they had their
first heterosexual (t = 2.19, df = 27, p < 0.05) and when they had their first
homosexual (t = 2.14, df = 22, p < 0.05) experience. There was no difference
between the groups with respect to the age at which the first crossdressing
experience occurred, although the trend was again toward a later first
experience for the mid-life patients. The older sex-change candidates also
tended on balance to have had more formal education than the younger
candidates (t = 1.84, df = 37, p < 0.10). The later initiation into sexuality
of our older sex-change candidates suggests that they experienced less intense
impulses in their youth than did their younger fellow applicants. Freedom
from sexual urges, especially those of an unconventional nature, could have
allowed more energy to be devoted to conventional educational pursuits.
One of the x2 analyses yielded significant results, and the two others
disclosed trends. The mid-life sex-change applicants were less likely than
their younger counterparts to have had at least one homosexual experience (x2
= 14.00, df = 1, p < 0.001). They also tended to be more likely to look
masculine (x2 = 3.40, df = 1, p < 0.10) and to be currently married and living
with their spouse (x2 = 3.53, df = 1, p < 0.10).
The homosexual contact rate of under 30% is consistent with the observation
of Steiner et al. (1976) that older gender dysphoria patients are less likely
to act out their homosexual impulses than younger patients. The older
patients' lesser femininity presumably reflects their having reluctantly
assumed lifelong masculine roles, as well as the ravages of age. However,
keeping in mind that the older applicants by definition waited longer before
requesting sexual reassignment than the younger applicants, part of the
variance could also be explained by a less intensely experienced degree of
transsexualism. Although the relatively high number of live-in marriages
among our middle-aged sample of sex-change seekers may at first glance seem
counterintuitive, it is compatible with the findings of both Steiner et al.
(1976) and Lothstein (1979). Marriage may reflect a certain degree of
resignation with regard to a transvestic existence, a developmental resolution
reached by older patients but passionately resisted by the younger patients.
Unlike the situation where our mid-life sex-change candidates were in their
youth, today's young adult applicants are aware of the changing sexual mores
and alternative lifestyles open to them and are also more vigorous in their
pursuit. Several of the findings are thus confluent in suggesting that mid-
life sexual reassignment candidates are somewhat more conventional and
resigned than their younger fellow applicants.
Table II. Comparative Characteristics of Vanderbilt Young Adult and
National Mid-Life Sexual Reassignment Candidates
Younger Older
Vanderbilt national
applicants applicants
Characteristic M SD N M SD N t value
Highest grade
completed 11.4 2.2 21 13.4 4.4 18 1 84a
Age at first
crossdressing 13.7 7.2 18 15.1 13.9 21 0.38
Age at first
heterosexual experience 16.9 3.5 13 20.7 5.4 16 2
19b
Age at first
homosexual experience 15.2 5.3 18 21.5 8.7 6 2
14b
Yes No Yes No x2 value
At least one
homosexual experience 18 3 6 15 14.00c
Currently married
and living with spouse 2 19 7 14 3.53a
Feminine appearance 12 9 5 13 3 .40a
ap< 0.10.
bp < 0.05.
cp < 0.001.
Although we favor a developmental interpretation of the foregoing
differences between the younger and older sex-change applicants, the data are
also open to the notion of transsexual subtypes. Thus, our younger
transsexuals seem similar to Bentler's (1976) homosexual subgroup, and the
older transsexuals to his heterosexual subgroup. From this perspective, the
social upheaval of the 1960s and early 1970s is viewed as having produced a
"generational cohort" of more committed transsexuals whose resolve will prove
less subject to erosion over the life cycle.
Inferences drawn from the foregoing findings are constrained by the
shortcomings of survey research and archival (and often impressionistic) data.
These would include the question of representativeness of returns, the
possibility of socially desirable responding in the service of presenting
one's clinic in a favorable light, and the notorious unreliability of
institutional records. In the present instance, the data were provided by a
clinic chief two steps removed from the patient himself, whose characteristics
and behaviors were presumably observed by a primary clinician and entered into
the chart that became the information source. Furthermore, conclusions
reached on the basis of the current data must be regarded as very tentative
pending the incorporation of control groups into further research. Although
comparison with data obtained from the younger sample of Vanderbilt sex-change
applicants provided some basis for understanding the national data from a
life-cycle perspective, the local and unmatched nature of the contrast group
demands caution in interpretation. Finally, diagnoses were not standardized
across the participating clinics, and respondents obviously differed widely in
their familiarity in expertise with psychiatric classification.
Such weaknesses of the present study, however, need to be weighed against
its strengths. For example, an advantage of a survey strategy that
accommodates open-ended as well as close-ended responding is the gathering of
a wealth of data, clinically rich as well as descriptive and reflecting the
real-world concerns of the clinic respondents in addition to the literature-
based orientation of the investigators. Moreover, the inclusion of multiple
clinics enhances the representativeness and treatment-relevant implications of
the findings. Because the data were provided by different judges, the
likelihood is reduced that a bias or idiosyncrasy of any particular one
seriously distorted the results. In the interest of a more sensitive
appreciation for the factors underlying the mid-life male transsexual's
surgical request, future researchers would do well to use appropriate controls
for age and for other psychosexual disorders and to standardize diagnoses
through the use of DSM-III or one of the systems developed to permit more
refined differentiation of those disorders.
ACKNOWLEDGMENTS
The authors express their appreciation to Dr. Collier Cole, Ms. Kay Fink,
Drs. Ralph Fishkin, Fred Henker, Charles Horton, Leslie Lothstein, Embry
McKee, Ms. Judy van Maasdam, Drs. Jay Maxwell, Richard Murray, Lloyd Sines,
Betty Steiner, Jane Weinberg, and Paul Weinberg for providing the
questionnaire data or other assistance.
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