British

Journal

of Psychiatry

(1990),

157, 261—264

A Controlled Study of Psychological and Social Change after Surgical Gender Reassignment in Selected Male Transsexuals CHARLESMATE-KOLE,MAURIZIOFRESCHIand ASHLEYROBIN Of two groupsof 20 patientsacceptedfor genderreassignment surgery,onewas offered earlyoperationandthereforehadhadsurgerybyfollow-uptwoyearslater,whilethesecond wasstillawaitingoperationattwo-yearfollow-up.Althoughthegroupsweresimilarinitially, significant differences betweenthememergedat follow-upintermsof neuroticism andsocial andsexualactivity,with benefitsbeingenjoyedby the operatedgroup. Method

Hoemg (1982) described transsexuals as: “¿person.s who are born without physicalabnormality m their genital organs . . . they are assigned to the opposite sexand reared in that sex.And yet in spite of all this and often in the face of fierce resistance by parents and others, they develop, usually from the

earliestage,a paradoxicalgenderidentity... [whichis] permanent and unchangeable. Most transsexuals pursue

their aim of physicalsexchangewith fanatical fervour and the idea ... appears to dominate their entire existence.― Roberto (1983), reviewing an extensive literature, concluded that:

Referrals to the Gender Identity Clinic at Charing Hospital were routinely examined by a psychiatrist

Cross using

a standard history form at first attendance and, if the patient

proceeded

to surgery,

on acceptance

for the surgical

waiting-list. This form covered personal and family medical

and psychiatric history, development, education, work record, social and sexual relationships,

and the onset and

progress of the patient's transsexualism. At

the

same

points

in time

a psychologist

(CMX)

administeredthe Crown Crisp ExperientialIndex (CCEI; Crown & Crisp, 1979), which is designed to measure differentaspectsof neuroticsymptoms:free-floatinganxiety (FFA),

phobic

anxiety

(PHO),

obsessionality

(OBS),

“¿the clinicaldefinitionof adult transsexualismis based somatic anxiety (SOM), depression (DEP), and hysteria on a compositeset of characteristics. . . the beliefthat (HYS). CMK also administered the Bern Sex Role Inventory oneisa memberof theopposite sex.. . dressing and (BSRI; Bem, 1974, 1977, 1981),which sorts, in quantitative behaving in the opposite gender role. . . perceiving terms, self-assessmentsof 60 personalitycharacteristicsto oneself as heterosexual

although

sexual partners

are

anatomicallyidentical. . . repugnance for one's own genitals and the wish to transform them. . . and a persistent

desire for conversion

surgery.―

Transsexualism is seen in both sexes but males present more commonly for treatment. While gender reassignment surgery was first described over 50 years ago (Abraham, 1931), the stimulus for the large-scale application of surgery came many years later (Hamburger et al, 1953) with the publicity surrounding the Jorgensen case. “¿As of the beginning

assessmentand treatment for a minimumof sixmonths to confirm diagnosis,excludepsychosis,and assistin change of genderrole. Criteria includeda persistentwish(at least two years) to changegender, and demonstrableability to liveadequatelyin the chosengenderrole for at leasta year by working and becoming self-supporting in that role. Randell(1971)in additionsuggeststhat “¿the patientshould be better adjusted in the role they desirethan the role they had left . . . [and] must be willing to accept the limitations.―

of 1979 estimates of the number of adult Americans treated hormonally and surgically ranged from 3,000 to 6,000―while “¿as of mid-1978 approxi mately 40 centres in the western hemisphere offered surgical sex reassignment― (Harry Benjamin International Gender Dysphoria Association (IGDA),

defme ‘¿femininity'and ‘¿masculinity'as separate entities. Selection for surgery was dedded by the standards of care recommended by the IGDA (1985) and included psychiatric

In normal practice it was unusual for a patient to be referred for surgery in under two years and psychiatric surveillancecontinued for the two to three years patients spent on the waiting-list, as well as two years post operatively. The mean time, therefore, from first attendance

to surgery, for the minority of referrals that finally achieved

1985). Despite a significant increase in

the numbers treated since then, differences of opinion concerning outcome continue (Williams, 1987). A prospective controlled study of male transsexuals accepted for surgical reassignment is described here.

reassignment,

was about five years. All patients were treated

using a single-stage operation including penectomy, orchidectomy and the construction of a neo-vagina. Within three months of acceptance onto the operation waiting-list, 20 alternate patients from a serial list of 40

261

(meanage32.5years,range21-53 years)wereoffered early surgery while their alternate

was dealt with routinely

and

262

MATE-KOLE

ET AL

thus awaited operation at the usual time. All 40 patients

group A, 4.47; group R, 4.57) in both groups and

were re-examined after two years by a psychiatrist and

approximated

psychologistusing the sametest battery as before. At this

females(means:femininity,5.05;masculinity,4.79)rather

time the ‘¿advanced'operation

than to North American

group (group A) had had

surgeryabout one year and nine months previously,while the ‘¿routine' group (group R) was still awaiting surgery.

to Bern's reference group of North American males (means: femininity,

4.59;

masculinity, 5.12). Finally, there were no significant differences

on any measure

in the CCEI

(Fable

I). In

summary therefore, at the time of acceptancefor surgery groups A and R resembled each other closely in their

Resufte

histories

Comparison of groups on acceptance for surgery Selectionof alternate waiting-listpatients should produce satisfactoryrandom groups, and in fact the twogroupsdid havesimilarpersonalfamilyand psychiatrichistories(Fable I). Moreover, the groups had been selected for operation

and on all measures

employed.

Changes over two years from entry

to the surgical walling-list Applying the McNemar test for the significance of changes (Siegel, 1956), ratings showed a significant increase in social

on the basis of their psychiatric stability. The groups were

and sexual activity in group A but no change in group R (Table II). Operated patients became more active as far as degreerelationships,familypreferencesand identifications all types of sport were concerned and more active socially, were concerned. Both groups were closer to ‘¿mother' and with both family and friends. As working in the cross identified with her ratherthan with other family members. gender role was among the criteria for acceptance for (In this context Edgerton et a! (1982) point out that the surgery,the majority of both groups wereemployedwhen mothers of male transsexualsaccept the patient's condition accepted for the waiting-list. However, group A remained in most cases while the fathers do not.) The two groups also similar in their family constellations,

and as far as first

were also similar in employmentstatus and in their level of activity as far as a wide variety of social interests was

concerned. In both groups cross-dressingemergedat aroundthe age of six years. In sexual fantasy the overwhelming

TABLE II

Signjficantchanges duringtwo-year follow-upin social, sexual and work activity for transsexuals post-operatively

(groupA) or awaitingoperation(groupR)

majority

of patients sawthemselvesto be in the femalegender role but in sexual practice were asexual, probably because during their assessment

they had been treated with oestrogens

for

a significant time. The mean BSRI scores of the two groups were not significantlydifferent. Femininityscores (means:group A, 4.91; group R, 5@06)exceeded masculinity scores (means: TABLE I

More

(y@)Sport

activeSameLess activeMcNemar test

incompanyA 16229.4