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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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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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