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. REFERENCES Bentler. P. M. (1976). A typology of transsexualism: Gender identity theory and data. Arch. Sex. Behav. 5: 567-584. Solosow. N., and Weitzman, E. (1969). Psychosexual and ego regression in the male transsexual. J. Nerv. Ment. Dis. 149: 328-336. Gordon. N. (1978). Introduction to special issue on mid-life crisis. Psychiat. Opinion 15: Contents page. Lothstein, L. (1979). The aging gender dysphoria (transsexual) patient. Arch. Sex. Behav. 8: 43 1 -443. Meyer. J. (1974). Clinical variants among applicants for sex reassignment. Arch. Sex. Behav. 3: 527-558. Steiner. B., Satterberg, J., and Muir, C. (1976). Flight into femininity: The male menopause? Paper presented at the Canadian Psychiatric Association Annual Meeting, Quebec City, Canada, September 29 - 0ctober 1. Stoller, R. (1967). Transvestites' women. Amer. J. Psychiat. 124: 333-339. Van Putten, T., and Fawzy, F. (1976). Sex conversion surgery in a man with severe gender dysphoria. Arch. Gen. Psychiat. 33: 751-753.
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