Sex Reassignment Surgery: Historical,
Bioethical, and Theoretical Issues
By Leslie M. Lothstein, Ph.D.
The reported 68% - 86% overall success rates for sex reassignment surgery
must be viewed cautiously; the lack of long-term follow-up studies makes these
statistics misleading. There is evidence suggesting that some gender
dysphoric patients benefit primarily from sex reassignment surgery. Most such
patients, however, are secondary transsexuals who can benefit from various
modes of psychotherapy. Sex reassignment surgery should only be considered as
the last resort for a highly select group of diagnosed gender dysphoric
patients. As physicians learn new ways to diagnose and treat transsexualism,
either sex reassignment surgery will be abandoned as a routine treatment
modality or new predictive variables for choosing suitable patients for sex
reassignment surgery will be established.
Received Oct. 10, 1980; accepted Dec. 23, 1980.
From the Department of Psychiatry, University Hospitals of Cleveland
Address reprint requests to Dr. Lothstein, University Hospitals of Cleveland,
2040 Abingdon Rd., Cleveland, OH 44106.
Few psychiatric issues have stirred up as much controversy and emotional
turmoil as transsexualism and sex reassignment surgery. Those clinicians who
espouse sex reassignment surgery as a legitimate form of treatment view it
either as a palliative or a cure of the gender dysphoric patient's intense
social-psychological suffering. Most clinicians who recommend sex
reassignment surgery as the treatment of choice also tend to believe that
psychotherapy is useless with gender dysphoric patients. In support of their
view, they cite several positive follow-up studies on postoperative
transsexuals (1-3) and the American Medical Association Commission on Human
Sexuality's 1972 sanction of sex reassignment surgery as the treatment of
choice for diagnosed transsexuals (4). Moreover, a recent book, Controversy
in Psychiatry, mentioned sex reassignment surgery as a viable treatment
modality for selected patients in a medical center (5).
On the other hand, those clinicians who consider sex reassignment surgery
as an illegitimate form of medical-surgical treatment usually characterize it
as mutilative and antitherapeutic. They point to the complex psychological,
medical, legal, bioethical, and political issues that are neglected or
bypassed by sex reassignment surgery procedures. They argue that sex
reassignment surgery leads to mistreatment and mismanagement of the gender
dysphoric patient. In one study a majority of the 300 physicians queried
opposed sex reassignment surgery for transsexuals (6). In support of their
view, clinicians cite studies indicating that various modes of psychotherapy
can successfully stabilize the gender dysphoric patient short of sex
reassignment surgery (7-9). These studies suggest that some clinicians may
have prematurely accepted Hertz and associates' dictum that "transvestism [now
called transsexualism] resists psychiatric treatment" (10).
The debate among mental health practitioners has recently been fueled by
the closing of the Johns Hopkins Gender Identity Clinic (11) and by several
studies supporting sex reassignment surgery (reference 12 and an unpublished
study by S. Satterfield). Arguments both for and against sex reassignment
surgery, however, are based more on rhetoric than on hard evidence. Those who
believe sex reassignment surgery is beneficial for certain patients must
acknowledge the lack of hard empirical evidence supporting their views and the
lack of even acceptable diagnostic criteria for selecting good candidates for
sex reassignment surgery. Those who argue against sex reassignment surgery
must account for the reported wide spread patient satisfaction with the
procedures and evidence of resulting positive life changes. While DSM-III
addresses some of the confusing diagnostic issues among the gender identity
disorders, the new criteria do not deal with treatment issues. In addition
there are no standards for the medical-psychological care of patients with
profound gender dysphoria (transsexualism). As more and more patients request
sex reassignment surgery, the issue of appropriate treatment for them becomes
central. Indeed, ever since the sensationalism of the Christine Jorgenson
case (13), large numbers of patients have requested information regarding sex
change (14, 15). A combination of several factors - the availability of
surgery, media exposure, the existence of national and international referral
centers and information sources, and the establishment of many gender identity
clinics - has made it necessary for clinicians to take a stand for or against
sex reassignment surgery.
Of the currently estimated 30,000 transsexuals, as many as 10,000 may be
residing in the United States (16). One researcher, Prince (17), has even
suggested that the number of requests for sex reassignment surgery has reached
epidemic proportions. Indeed, a 1977 report estimated that over 1,000
surgical procedures would be performed in the United States in 1980 (16). As
long as there are no universally accepted standards of care, hospitals can
either prohibit sex reassignment surgery or make it routinely available to
gender dysphoric patients on a fee-for-service basis. If sex reassignment
surgery becomes a Medicaid-subsidized procedure, it could be performed on many
nontranssexual patients with gender dysphoria, who may later regret their
decisions. While all practitioners should be concerned about the unrestricted
use of sex reassignment surgery, it may be that for some patients sex
reassignment surgery is the treatment of choice. Those clinicians who espouse
sex reassignment surgery, however, must determine which gender dysphoric
patients are the best candidates for the procedure.
In spite of the many clinical research studies of transsexualism, very
little is actually known about the medical-surgical and social-psychological
effects of sex reassignment surgery. Many questions are left unanswered. For
example, which, if any, patients derive the most benefit from sex reassignment
surgery? What data support the continued use of sex reassignment surgery as a
treatment regimen? What is the crucial test for determining the prescription
of sex reassignment surgery?
To my knowledge there has not been a single comprehensive review of the
published sex reassignment studies or an analysis of their results. It is the
aim of this paper to address these issues by reviewing and examining the
historical roots, assumptions, and findings of the major studies. In this
context, suggestions for future research strategies and directions for
treatment will be made.
SEX REASSIGNMENT SURGERY THROUGH THE 1960s
The historical, cultural, anthropological, and literary development of
sexual transformation and surgery is well documented (18-21). Green (22)
cited incidences of sexual transformation procedures in early Greek and
classical history, the Renaissance, and modern times: cultural examples from
American Indian tribes as well as Indo-European and Asiatic cultures are
included. Throughout history instances of autocastration and genital
mutilation, the result of an individual's intense desire to change sex have
been reported (23). Translating the desire for sex reassignment surgery into
a reality, however, required the advances of modern surgical technology and
hormonal procedures. In the following reviews of surgery follow-up, the
studies are reported chronologically.
While Abraham (24) reported on the first sex reassignment surgery of two
male transvestites in 1931, it was not until the publication of Lilly Elbe's
autobiography (25) that sex reassignment surgery became a popular and
practical solution for the transsexual's dilemma.
The first significant postsurgical findings were reported by Hertz and
associates (10). That study investigated the postsurgical functioning of 2
male and 3 female transvestites (including one who changed back to his male
role after 7 years). The mean postsurgical period was 7.8 years (range = 3.5
to 16 years). Follow-up data on 4 patients' social-emotional states suggested
satisfactory outcome. The evaluative criteria were based on the impressions
of the investigators. A review of the findings suggests some discrepancies
with usual clinical assessment in that one patient who was judged to have a
satisfactory outcome was actually a depressed drug addict who engaged in
homosexual prostitution.
The beginning of serious research in the field was initiated with the
publication of Benjamin's classic follow-up study (1) of postoperative
transsexuals. Of 73 men and 20 women who underwent surgery, 85% of the men (N
= 62) and 95% of the women (N = 19) showed satisfactory outcomes. These
figures were derived by classifying postsurgical patients into three
categories: unsatisfactory, good, and satisfactory. The assignments were
based on impressionistic evidence, patients' self-reports, and anecdotal
material about the patients' postsurgical social-biological-psychological
status. There were no attempts to obtain standardized data from each patient;
no demographic data were provided. The overall 87% improvement figure
included patients in both the good and satisfactory groups.
Money and Brennan's study (26) of 6 postsurgical women corroborated
Benjamin's findings. They concluded that "the evidence to date is that sex
reassignment does indeed improve the human condition of the afflicted
individual." However, neither of these studies separated the male and female
groups on any basis whatsoever. Since most theoreticians regard female
transsexualism as diagnostically and dynamically distinct from male
transsexualism (27), one would expect that such a methodological error could
lead to faulty conclusions.
In his 1968 review (28) of the world literature on 121 cases, Pauly
concluded that a group of transsexuals who underwent sex reassignment surgery
was 10 times more likely to have a satisfactory outcome, in terms of social
and emotional status, than a group who did not. These findings have provided
the bedrock for continued support of sex reassignment surgery.
Randell (2) reported postoperative results on 29 men and 6 women
(postsurgical follow-up ranged from 3 months to 7 years). According to the
male and female adjustment ratings (including acceptability as a male or
female, subjective satisfaction, social adaptation, and physician's
assessment), 72% of the men and 83% of the women had satisfactory outcomes.
Although 2 men committed suicide, Randell concluded that the patients
demonstrated lessened environmental conflicts, significantly decreased levels
of anxiety and depression, and improvements in family relations and
employment.
The studies of the 1960s ended on a less positive note as Golosow and
Weitzman (29) reported on a single case involving a man who was hospitalized
with severe depression and regressed behavior 15 months after sex reassignment
surgery. The patient had been provided with sexual surgery despite the lack
of a life long gender conflict. Benjamin (1) had previously described a case
of a 56-year-old man who expressed regret after surgery and was later
reassigned back to his male role.
Money and Primrose (30) reported that none of their 12 postoperative male
transsexuals exhibited a maternal response. This finding was amplified by
Newman and Stoller (31), who hypothesized that male transsexuals are not
capable of achieving womanhood, since they have not experienced the usual
developmental pathways and oedipal conflicts of biological girls and only
exhibit surface-shallow female characteristics. They concluded that although
surgery may change a person's secondary sexual characteristics, the inner male
or female identity remains untouched. Unfortunately, no further analyses of
the inner psychological feelings of postoperative transsexuals were performed.
Summary
With one exception the follow-up studies up to and throughout the 1960s
focused entirely on gross social-psychological measures of improvement. The
consensus of these studies was that sex reassignment surgery was the treatment
of choice for transsexualism. In spite of a few negative outcomes involving
suicide (2), psychiatric disturbances (30), and role re-reversal (1), most
investigators were optimistic about sex reassignment surgery. Citing an 80%-
90% cure rate for sex reassignment surgery, investigators generally accepted
the fact that traditional psychiatric intervention was useless with
transsexuals and that sex reassignment surgery was the treatment of choice for
transsexualism. However, clinicians outside the area of transsexual research
were not so accepting of these conclusions (32).
SEX REASSIGNMENT SURGERY THROUGH THE 1970s
Throughout the 1970s increasing numbers of patients sought sex reassignment
surgery. Many of these patients were secondary transsexuals who, under
stress, expressed a regressive wish for sex reassignment surgery. Spurred on
by changing views of societal sex roles, large numbers of patients were given
external support to change their sex rather than to understand the nature of
their psychological distress. Moreover, lacking a formal schema to diagnose
gender dysphoric conflicts and lacking standards of medical-surgical care, the
profession of psychiatry was unprepared to adequately respond to the
transsexual's dilemma. In addition, since sex reassignment surgery was
available to almost any self-labeled transsexual who could pay the fee and the
surgery was often performed secretly, few of them were available for follow-
up. There was little that psychodynamically oriented psychotherapists could
do to intervene using psychological methods.
In spite of the many difficulties outlined, the initial studies of the
results of sex reassignment surgery in the 1970s widened the criteria for
investigating the postsurgery patient and contributed significantly to
advances in our knowledge of gender identity disturbances.
In the apparently first published study of the 1970s, Money and Ehrhardt
(33) investigated 17 men and 7 women and compared the patients' preoperative
and postoperative adjustment along five dimensions: capacity for a lasting
relationship with a partner, adjustment to work, criminality, mental state,
and patients' subjective opinion of the result. Only one woman was reportedly
dissatisfied with the cosmetic results, but she stated that she would undergo
the procedure again. The patients' satisfactory adjustment on all levels led
to the conclusion, "If one is able to stipulate specific criteria for sex
reassignment surgery, then it can be seen that the outcome of sex change, that
is, the psychological and social situation of transsexuals, is oftentimes
better than worse" [my translation]. The conclusion was somewhat illusory in
that no universally acceptable criteria for patient selection were provided.
In the second study of the 1970s, Hoenig and associates (34) reviewed the
literature on sex reassignment surgery and reported on a follow-up study of 8
of their own patients (5 men and 3 women). One of the women and 4 of the men
were judged to be psychiatrically disturbed; 1 of the men had had a leucotomy.
Although 1 patient was judged to have a poor outcome, none of the patients
expressed regret over the surgery. The 12% failure rate supported the
authors' conclusion that "the treatment helps the majority of patients both
subjectively and objectively... but the operation can in no sense be regarded
as a cure." This was the first study to acknowledge the high incidence of
psycho-pathology among postoperative transsexuals and challenged the notion
that sex reassignment surgery could cure the transsexual's distress. Indeed,
2 years later Money and Wolff (35) reported on a male transsexual whose
postoperative depression was so severe that he was later reassigned to his
male role. They attributed the poor results to a deficient presurgical
evaluation. The possibility of surgery's proving harmful has been supported
by a number of single case studies (36-38).
At Northwestern Medical Center Arieff (39) studied 14 men and 4 women for 5
years after surgery. The group included 3 blacks and 1 Oriental. Nine
patients (50%) demonstrated better social adjustment; 2 patients (11%) had
better vocational adjustment; 5 (28%) improved their relationships by getting
married; and overall conditions worsened for 2 patients (11%). While the
amount of overlap among the groups is unclear, it is apparent that the
majority of patients were not cured.
While Gandy (40) supported the use of objective criteria to assess outcome
(social and economic improvement and subjective feeling of happiness), his
report of the preliminary findings of the Stanford group indicated that
surgery on demand would probably be disastrous. Unfortunately, he did not
elaborate on this view.
On the other hand, Ihlenfeld's review (41) of Benjamin's findings indicated
that most adult transsexuals achieved good results with sex reassignment
surgery (although 5 of the patients died from mysterious drug-related
accidents). Ihlenfeld's optimism about sex reassignment surgery led him to
argue for the possible surgical benefits for transsexual patients in their 50s
and 60s.
Hastings and Blum (42) reported on 25 men who received sex reassignment
surgery at the University of Minnesota. Using a college grading system (A, B,
C, and D), they rated patient outcome on sexual, economic, and social
variables. Twelve patients experienced multiple orgasms; 12 patients were
marginally self-supportive; 8 were on welfare; 10 patients were married,
including 6 who had remained with their original spouses. Despite 1 who
attempted suicide, satisfactory adjustment was reported for all the patients.
There was no indication of the degree of overlap among the variables of change
investigated. One case warrants reporting in detail because of its
consequences. In that case a patient who mutilated his genitals and had a
prison record was eliminated as a surgical candidate. The patient's threat of
suicide, however, prompted Hastings and Blum to bring in six outside judges
from Minneapolis. The judges urged the clinic to perform surgery: 1 month
after surgery the patient reverted to living as a man. In another instance
one of their clinic staff members recommended 5 psychopaths for sex
reassignment surgery to see if this procedure would cure their character
problems. He eventually concluded that sex reassignment surgery is not a cure
for psychopathy.
Laub and Fisk (43) reported on 74 patients - 50 men and 24 women - who
received sex reassignment surgery. (At the 1980 APA annual meeting the
Stanford team updated their statistics, reporting that 131 men received
vaginoplasty, 75 women received phalloplasty, and 86 women received
mastectomies.) Thirty-eight of the men had surgery at Stanford. They
evaluated patients' employment, social-psychological, and sexual adjustment
using a grading system similar; to that used by Hastings and Blum. Five
patients were unavailable for follow-up. Although 1 patient regretted having
surgery and another committed suicide, they concluded that sex reassignment
surgery did not significantly harm any patients. They reported significant
improvement in all but the psychological areas of functioning. This study is
important because the surgical group included nontranssexuals, e.g.,
effeminate homosexuals and transvestites, and the researchers separated the
psychological from the social domain. The term "gender dysphoria syndrome"
was used to describe patients who requested sex reassignment surgery. Laub
and Fisk concluded that "transsexuals are not the only group that can benefit
from this type of surgery." Preoperative behavioral adaptation to the new
gender role, not psychiatric diagnosis, was found to be the best predictor of
postsurgery outcome. This was apparently the first study that mentioned sex
reassignment surgery as a treatment for nontranssexual disorders.
At the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome,
Fisk (44) reported on the postsurgical follow-up of eight men who had been
diagnosed as psychotic or schizophrenic (with delusions focusing on sexual
identity). Their postoperative improvement was so marked that Fisk labeled
them "eight spectacular cases"; the number has recently been reduced to 5
(45). Fisk felt that sex reassignment surgery could result in remission for
some psychotic or schizophrenic individuals whose disturbances focused mainly
on sexual identity. Prior to this report, all surgical centers had refused to
operate on schizophrenic or psychotic patients. Schizophrenic patients with
delusions of sex change had been known to request sex reassignment surgery
(46). The suggestion that sex reassignment surgery might prove beneficial for
schizophrenic patients represented a major departure from current thinking.
Gottleib (47) reported on the follow-up of 9 transsexuals, including 1 who
was left decorticate secondary to anesthesia, 1 who was postoperatively
labeled a "freak," and a 23-year-old male-to-female patient who adopted a
lesbian role after surgery. Biber (48) reported on 1 schizoid patient who was
in the process of being reassigned back to his biological maleness. In light
of these poor outcomes, a well-known author and transvestite, Virginia Prince,
suggested that more attention be paid to nonsurgical alternatives for
transsexuals, noting that, at least in California, "sex reassignment surgery
is a communicable disease" (personal communication, 1977).
Hore and associates (49) reported on 16 English transsexuals who were
studied for 6 to 18 months after surgery. For 11 patients (69%) the surgery
was judged beneficial, i.e., they felt more feminine, had increased
confidence, and were emotionally and sexually better adjusted; 2 of them
married. However, 5 patients expressed dissatisfaction; 3 were dissatisfied
with the cosmetic results, and 2 did not feel completely female. Eight of the
11 patients (73%) had long histories of psychiatric illness. These results
were consistent with the findings of Hoenig and associates (34).
Money (50) reported on one of the youngest patients to have sex
reassignment surgery. The patient was a male twin whose penis had been
amputated secondary to an accident during circumcision. The child was
surgically revised to a female at age 17 months and is being raised as a girl.
Recent follow-up suggests a good outcome.
In a study conducted at Vanderbilt University, McKee (51) reported on 7 men
and 4 women who had received surgery but did not provide detailed notes on
their social-psychological condition.
Walinder and Thuwe (3) conducted the most comprehensive follow-up study to
date. They examined the social-psychiatric histories of 24 reassigned
transsexuals; detailed histories for each patient were included in the report.
Eleven men and 11 women were available for follow-up; 2 men were not. They
expanded on Money and Ehrhardt's five follow-up criteria (33) by elaborating
on the social aspects, e.g., place of residence, Social Security benefits,
alcoholism, criminality, periods of certified sickness, and disability
pensions. Other adjustment criteria included sexual life (propensity and
strength), housing conditions, attitudes of relatives, work records, patients'
subjective opinion, and investigators' assessment (including psychological
state and appearance). By studying their patients at least 3 years
postoperatively, they tried to eliminate the usual immediate postsurgery halo
effect. They found that the biological females generally had a better
outcome; 2 men (18% of the men) regretted having surgery. Overall, 91% of the
women and 69% of the men had satisfactory outcomes. These results are
consistent with those of Benjamin (1), Randell (2), and Money and Ehrhardt
(33). The small sample size precluded the possibility of obtaining
statistically significant presurgery and postsurgery differences. Walinder
and Thuwe concluded,
Taking men and women together, the outcome was clearly favorable in
approximately 80% of the cases. The proportion of unsuccessful cases in our
series is about the same as that found by Hoenig et al in a review of
previously published follow-up cases. When we considered the severe suffering
and the many difficulties experienced by untreated transsexuals in various
fields of life, the treatment programme appears to be fully justified both
medically and ethically.
Sturup (52) clinically evaluated 8 of 10 patients up to 19 years after sex
reassignment surgery. Two had died; half of the remaining patients exhibited
severe adjustment problems. All but 1 reported psychological problems,
including difficulty at work, sexual maladjustment, depressive ideation,
suicidal behavior, familial rejection, continuous living in the male role, and
reactive psychosis. In spite of these difficulties, all of the patients were
satisfied with the surgical results.
Lothstein (53) studied two groups of patients after sex reassignment
surgery. Group 1, consisting of 7 biological males, had sex reassignment
surgery before the establishment of a gender identity clinic at Case Western
Reserve University Medical School. Group 11 (8 biological males and 6
biological females) had surgery after intensive evaluation and long-term
psychological and medical treatment. The average postsurgery time span was
1.9 years (range = 0.5 to 3.5 years). Systematic data were gathered on each
patient in group 11 prior to surgery. Patients completed a 59-item
questionnaire focusing on sexual, psychological, environmental, economic,
parental, family, medical, and social adjustment and functioning. This was
apparently the first research study in which patient data were systematically
collected and each patient was required to participate in intensive
psychological treatment.
The results suggested moderate postsurgical social and sexual gains
accompanied by marked depression and psychological confusion. However, all
patients reported being subjectively satisfied with the surgery. It was
concluded that character structure and neurotic functioning are not
permanently altered by sex reassignment surgery. Moreover, all patients
should be routinely provided counseling and/or psychotherapy to help them
adjust to their new social-psychological status. Sex reassignment surgery
does not facilitate the patient's psychological integration of gender role and
identity; this integration requires psychotherapy. A major conclusion of this
study was that all preoperative and postoperative gender dysphoric patients
should undergo psychotherapy.
In the most controversial study, Meyer and Reter (11) studied 100 patients
who applied for sex reassignment surgery at the Johns Hopkins Gender Identity
Clinic. Of these, 34 underwent surgery (24 at Johns Hopkins and 10 elsewhere)
and 66 failed to qualify for surgery. Only 15 of the 34 surgery patients (44%
of the sample) were available for follow-up, 17 were lost to follow-up and 2
refused to participate. Of the 66 nonsurgery patients (the control group), 35
(53%) were available for follow-up and 31 were lost to follow-up. In summary,
only 50% of the 100 patients were available for follow-up. Fourteen of the 35
nonsurgery patients later received surgery, including 5 patients at Johns
Hopkins; the remaining 21 patients were still interested in obtaining surgery.
The surgery group (average age = 30 years) was studied for a mean of 5.0 years
(range = 19-142 months); the nonsurgery group was followed for 2 years (range
= 15-48 months). Four blacks were included in the group.
Since there was no breakdown according to socioeconomic status, education,
and race, the effect of interaction among these variables is unknown. All
data except years of schooling were reported in percentages. The measured
variables included change of residence; job and educational levels; prior
psychiatric treatment; and overall assessment score derived by using an
arbitrary scaling method on legal, economic, marriage, cohabitation, and
psychiatric histories. Psychotherapy was not provided, and there was little
information on psychological functioning. While there were no statistically
significant differences among the initial adjustment categories, the trends
did suggest that the surgery group showed the greatest changes over time.
This finding was not elaborated on. Meyer and Reter concluded that "sex
reassignment surgery confers no objective advantage in terms of social
rehabilitation although it remains subjectively satisfying to those who have
rigorously pursued the trial period and who have undergone it." As a result
of a press release, these findings were used as evidence to close the surgical
program at Johns Hopkins. In the last analysis, the decision seemed to be the
result of political pressure and not to be based on the empirical findings of
the study.
Hunt and Hampson (12) reported on the follow-up of 17 biological males
(mean of 8.2 years after surgery). While the patients reported gains in
sexual satisfaction, family acceptance, economic functioning, and
interpersonal relationships, there were no changes in the incidence of
psychopathology. Although none of the patients regretted having the initial
surgery, 24% still felt a "driven need for further surgical procedures." The
authors concluded that for a select group of transsexuals, "surgery will
continue to offer... the best means of coping with this dilemma." They
cautioned, however, that sex reassignment surgery does not alter personality;
the best predictors of postsurgical success are presurgical ego strength and
patients' "adjustment during the presurgery period while living in their new
gender/sex role."
At the 1980 APA annual meeting in San Francisco, Satterfield (unpublished
study) reported the preliminary findings of a follow-up of the original group
described by Hastings and Blum. The 22 postoperative transsexuals included 3
female-to-male patients (average postsurgery period = 3.8 years) and 19 male-
to-female patients (average postsurgery period = 9.2 years). All patients
agreed to the interview and assessment and gave favorable responses about the
surgery on the structured interview and psychological assessment tasks.
Patients were physically examined by a psychiatrist also trained in plastic
surgery, were given a battery of psychological tests including the MMPI, SCL-
90, and Zung depression inventory, and were asked to complete an elaborate
questionnaire. Whenever possible, material from hospital charts and therapy
notes was used. None of the patients expressed regrets about having surgery,
and all showed "a significant improvement in psychological functioning." A
global measure of improvement was derived based on responses to interview
material and psychometric testing. The minimal presurgery screening in the
original program made it necessary to base many of the conclusions on post hoc
analysis. The relationship between quality of surgical results and good
psychological functioning was found to be statistically significant among 16
patients who changed from male to female (p < .01).
Summary
The studies of the 1970s and early 1980s challenged the idea that sex
reassignment surgery was a cure for transsexualism. While prior findings that
sex reassignment surgery leads to better socioeconomic functioning for some
patients were given additional support, gender dysphoric patients were
characterized as having severe psychopathology that was unaltered by sex
reassignment surgery. As an outgrowth of these studies, it was suggested that
candidates for sex reassignment surgery receive preoperative and postoperative
counseling and/or psychotherapy. Sturup (52) supported this idea, noting, "In
some of the early cases the reluctance on the part of therapists to adopt an
active therapy [had] been too great."
While some of the postsurgery studies attempted to identify predictive
variables for use in patient selection for surgery, no uniform diagnostic
criteria were identified or employed. Despite attempts to address the serious
methodological problems of the earlier studies, the studies of the 1970s ended
on a sour note. The media distortion of the Johns Hopkins results suggested
that sex reassignment surgery was of little or no benefit - a conclusion
unsubstantiated by the data but one that has become the focus of much debate.
DISCUSSION
Methodological Problems of Follow-Up Studies
Most of the 785 postsurgical patients (approximately 596 men and 189 women)
who have been studied are self-selected; they have voluntarily enrolled in a
hospital- or university-based gender identity clinic. Their intense
surveillance includes an extended psychological and behavioral evaluation that
often lasts over 1 year. A review of follow-up studies suggests that gender
clinics' surgical requirements can be met only by patients who can cope with
delayed gratification and frustration; they may even be somewhat passive and
compliant. However, these patients represent only a small percentage of the
estimated 30,000 self-labeled transsexuals, of whom 3,000-10,000 have
reportedly received sex reassignment surgery. The vast majority of gender
dysphoric patients obtain sex reassignment surgery on a fee-for-service basis
without benefit of a prolonged diagnostic evaluation. As a group they are
probably more impulsive, impatient, anxious, and demanding of sex reassignment
surgery than are those who enroll in university-based clinics. Many of these
patients are probably secondary transsexuals who feel surgery will relieve
their emotional distress. Unless these patients need additional surgery, they
will be generally unavailable for follow-up. The lack of baseline data on
their presurgical psychological states makes it impossible to evaluate the
changes caused by sex reassignment surgery. More over, neither the surgeons
who perform sex reassignment surgery on demand or their patients seem to be
interested in understanding the psychological roots of transsexualism.
In order to apply the results of these follow-up studies to the wider group
of postsurgical transsexuals, we must determine whether those who have been
studied represent an adequate cross-section of all sex reassignment surgery
patients. If not, this sampling bias is a primary methodological problem
inherent in all of the published studies on sex reassignment surgery. A
review of those studies reveals other serious methodological problems,
including a lack of universally accepted criteria for diagnosing gender
dysphoria and determining suitable candidates for sex reassignment surgery;
lack of an adequate control group; considerable variability among programs in
gender identity clinics as well as in the quality, training, and experience of
clinical staff; failure to include basic data on patients' race and age;
frequent use of nonoperationalized criteria for improvement, such as patients'
subjective feelings of happiness; use of college grade level systems for
evaluating outcome; failure to provide data on the length of time between
evaluation, surgery, and follow-up; failure to use uniform diagnostic labels;
failure to use standardized clinical instruments to assess patients, even
within a single study; limitation of clinical investigation to gross, social-
psychological variables; failure to include in-depth psychological analysis;
use of hypothetical post hoc analyses to provide missing presurgical data; and
use of biased evaluators to interpret outcome data. This list is by no means
exhaustive.
These methodological difficulties can be addressed by providing all sex
reassignment surgery patients with uniform clinical interviewing, questioning,
evaluation, and treatment schedules and follow-up questionnaires. To date
only one follow-up study has attempted to fulfill some of these requirements
(53). While there are still no uniform criteria for patient selection for sex
reassignment surgery, the Harry Benjamin International Gender Dysphoria
Association has formulated some elementary standards of care for transsexuals
(16). This work needs further elaboration before it can become a model.
Researchers can begin to overcome the difficulty of small samples by combining
data from several clinics. This practice would obviously necessitate the use
of standardized clinical instruments, clinicians with similar training back
grounds, and uniform criteria for evaluation and treatment. The crucial
problem, however, is the availability of patients for follow-up.
Overview of Findings: Two Decades of Research
A review of the studies on sex reassignment surgery reveals a diversity of
factors used to investigate postsurgical patients (appendix 1). Results
differ depending on which factors are focused on. For example, those
clinicians who used global ratings found a positive change rate of 68%-86% in
the patients' overall social-emotional functioning. On the other hand, those
who used more discriminative evaluation criteria (focusing on psychological
variables) not only failed to replicate these success rates but occasionally
reported negative outcome in the socioeconomic area of postsurgical
functioning. All of these findings must be viewed in light of the various
methodological weaknesses of the studies reported earlier.
Appendix 2 summarizes the positive and negative findings of the studies of
sex reassignment surgery for over two decades of research. Although several
categories of change have remained constant, the more recent studies have
focused on negative psychological functioning after surgery. These findings
may be directly related to the increased number of surgical procedures
performed. However, previous researchers had also sorely neglected the
measurement of psychological functioning after surgery. Perhaps the early
postsurgery studies failed to report on psychological dysfunction because the
evaluators, who were physicians and surgeons, lacked clinical psychiatric
expertise. Indeed, many of them believed that sex reassignment surgery would
completely change the patient's personality structure for the better - thereby
abrogating previous psychological disturbances. While no single study has
intensively evaluated the global psychological status of postsurgery patients,
the recent focus on psychological variables and especially psychotherapy (54-
56) represents an important direction for research.
An analysis of those postsurgery studies which focused on the patient's
psychological functioning revealed considerable discrepancy. This was
partially related to the definition of "psychological functioning." The term
(which has been used to describe anything from the frequency of psychiatric
visits to responses to personality tests and data from psychotherapy) needs to
be refined in terms of acceptable clinical criteria. Moreover, the status of
patients' self-reports about their subjective satisfaction or happiness with
that procedure needs to be reconsidered as the sine qua non of outcome.
In a preliminary way the studies of the 1970s challenged the notion that
sex reassignment surgery led to complete psychological integration of the
patient's new gender role and identity. While sex reassignment surgery may
have provided the transsexual with artificial genitals, it did not provide the
patient with the developmental history of a man or woman necessary for being a
male or female, e.g., for the man, unique identifications with the mother,
typical female preoedipal and oedipal development, experience of participation
in a girls' social group, menses, and continued social-psychological reactions
to female development. While psychotherapy can be of considerable benefit for
the gender dysphoric patient, it cannot provide the internal structures of
maleness or femaleness necessary for internalizing cross-gender
identification. These identifications are primary structures established
during early childhood and are not to be gained through sex reassignment
surgery or psychotherapy. One must not confuse cross-gender social role
adaptation with one's internalization of gender identifications.
What, then, does happen after surgery with the gender dysphoric patient?
In determining the success of sex reassignment surgery, should one use only
the results of medical-surgical procedures (i.e., whether the new genitalia
appear realistic and are functional)? Or ought one to be concerned about the
patient's psychological status? While sex reassignment surgery is an invasive
and irreversible procedure, presumed by some investigators to have a negative
psychological effect on the patient, many questions are still unanswered by
the research. Do postsurgery patients exhibit more or less depression,
anxiety, or guilt? Are postsurgery patients more or less suicidal or
psychotic? What are the psychological sequelae of male castration and penile
amputation and female mastectomies and hysterectomies? While these clinical
questions have not been fully answered by researchers, they certainly need to
be addressed. While most studies focus on variables that they have related to
successful outcome, e.g., social, vocational, economic, and familial
variables, future researchers need to refine their questions. In spite of the
apparent objectivity of these social variables, they are no less dependent on
one's framework of values than more complex psychological variables. For
example, is a shy, with drawn, schizoid low-paid clerk who undergoes sex
reassignment surgery and becomes an outgoing, highly successful female
impersonator or prostitute (earning a high income and having a wide variety of
social relationships) considered a success or failure? What are the criteria
used to determine outcome? Bioethical dilemmas such as this need to be
addressed.
CONCLUSIONS
The reported 68%-86% success rates for sex reassignment surgery must be
viewed cautiously. The lack of long-term follow-up studies makes these
statistics misleading. As long as sex reassignment surgery remains a viable
treatment modality, it is reasonable to ask how one determines which patients
will most benefit from sex reassignment surgery. Currently the selection
criteria available are informally culled from clinical guidelines established
by the various gender identity clinics nationwide. These criteria might be
used in establishing universally acceptable guidelines for referring a patient
for sex reassignment surgery. In order for these guidelines to be effective
one would have to ensure that sex reassignment surgery was done only by
skilled surgeons in highly selected university-based clinics that could
provide follow-up. Essentially, this would mean limiting all sex reassignment
surgery to a select number of hospitals in the United States. While this
raises certain ethical issues, it is clear that current abuse comes from the
widespread availability of sex reassignment surgery and not the other way
around.
While sex reassignment surgery has definite medical-surgical and
psychological limitations, there is insufficient evidence to warrant its
termination. In deed, there is evidence suggesting that some gender dysphoric
patients benefit primarily from sex reassignment surgery (reference 12 and an
unpublished study by S. Satterfield). The problem is how to identify these
patients. The growing body of literature implicating a neurohormonal
hypothesis in gender dysphoria (57) also cannot be used to justify sex
reassignment surgery, since the disorders of gender dysphoria are primarily
psychological disorders, and it is rare to substantiate a neurohormonal
disorder for any given case. Most gender dysphoric patients, however, are
secondary transsexuals (58) who can benefit from various modes of
psychotherapy (54-56). To date the evidence suggests that many patients who
would have otherwise undergone sex reassignment surgery may adjust to a
nonsurgical solution through psychotherapy (7). Moreover, many misdiagnosed
gender dysphoric patients need psychotherapy, not surgery (59). Indeed, sex
reassignment surgery should only be considered as the last resort for a highly
select group of diagnosed gender dysphoric patients. It is imperative that
legislators who wish to provide Medicaid payments for transsexual surgery
understand that, in most cases, alternatives to sex reassignment surgery are
available to patients. Physicians wishing to refer a patient for evaluation
for sex reassignment surgery should be allowed to make use of the many
specialized gender dysphoria clinics that are currently in operation.
As clinicians learn new ways to diagnose and treat transsexualism, either
sex reassignment surgery will be abandoned as a routine treatment modality
(reserved for only a few select patients) or new predictive variables for
choosing suitable patients for sex reassignment surgery will be established.
Future research needs to focus on long-term follow-up studies maximizing the
use of those methodological issues outlined in this paper which will enhance
our understanding of the etiology and the course of gender identity disorders.
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APPENDIX 1. Factors Investigated by Various Studies of the Results of Sex
Reassignment Surgery
1. Medical
2. Surgical
a. Patients' evaluation
b. Physicians' independent assessment
3. Psychological
a. Psychometric scales
b. Psychiatric interview
c. Number of psychiatric contacts
d. Number of psychiatric hospital admissions
e. Suicide attempts
f. Evidence of psychiatric symptoms
4. Environmental
a. Vocational and economic status
b. Living conditions
c. Income, amount and source
d. Criminality
5. Ability to pass in the new role successfully
6. Use of drugs and alcohol
7. Family and marriage
a. Capacity for a lasting relation with partner
b. Parental support
8. Sexual adjustment
9. Patients' subjective feelings about the surgical result
10. Patients subjective feelings of happiness
11. Overall assessment of result-global ratings
a. Social rehabilitation
b. Social-psychological
c. Social-economic-psychological
d. Social-biological
APPENDIX 2. Summary of Positive and Negative Factors of Studies of the
Results of Sex Reassignment Surgery Over Two Decades
1960s
Positive factors
1. Acceptability as a man or woman
2. Subjective satisfaction with surgery
3. Social Adaptation
a. Lessened conflict with the environment
b. Improved family relations
c. Increased capacity to work, new and better job status
3. Social adaptation
4. Physicians' assessment of surgical results
5. Psychological changes
a. Decreased levels of anxiety
b. Decreased level of depression
Negative factors
1. No maternal response
2. Failure to develop an inner schema of femaleness
3. Suicidal threats, gestures, and behaviors
4. Psychiatric disturbances, including drug addiction and depression
5. Role re-reversal, requests for re-reassignment
6. Homosexual prostitution
1970s
Positive factors
1. Subjective satisfaction with sex reassignment surgery
2. Increased sexual satisfaction
3. Remission of certain forms of schizophrenia
4. Increased vocational-economic adjustment
5. Improved psychological status correlated with good surgical results
6. Patient's subjective feelings of happiness
7. Lessened conflict with the environment
8. Decrease in acute symptoms
Negative factors
1. Requests for more surgery
2. Increased psychiatric illness (73% in one study)
3. No change in psychological status
4. Poor cosmetic appearance
5. Requests for reversal of surgery
6. Massive lawsuits
7. Medical problems (e.g., one patient left decorticate, another
having a leucotomy)
8. Patient left in "freak status," cannot pass in new role or adopts a
lesbian status after male-to-female sex reassignment surgery
9. Suicidal threats, gestures, and behaviors