|
Sex Reassignment of Adolescent Transsexuals:
A Follow-up Study
Cohen-Kettenis PT, van Goozen SH.
Department of Child and Adolescent Psychiatry,
Rudolph Magnus Institute of Neurosciences,
Utrecht, The Netherlands
Abstract
| Full Text [PDF]
Strong feelings of belonging to the opposite
sex and corresponding behavioural manifestations have been reported as
beginning as early as 2 to 3 years of age (Zucker and Green, 1992).
Prospective studies have shown that most children with gender identity
disorder will not grow up to become transsexuals (Green, 1987; Zuger, 1984).
In a few, however, the cross-gender feelings will remain. These individuals
become adolescents who will attend gender identity clinics to obtain sex
reassignment surgery (SRS). Despite the early onset of the disorder, in most
countries it is common practice not to start the actual SRS procedure
earlier than 18 or even 21 years of age. There are several reasons for this
long delay.
In pre-pubertal children medical treatment
is never considered because of the previously mentioned discontinuity
between gender identity disorder of childhood and adult transsexualism.
However, there is a general reluctance to commence rather invasive
procedures such as hormone treatment even in post-pubertal children.
Adolescence is a phase in which many identities, e.g. political or
religious, are developed. Professionals fear that experimenting with certain
aspects of gender, such as gender role behaviour, will lead adolescents to
conclude that they have a gender identity problem and that they, will as a
result wrongly seek a medical means of resolving their confusion. The chance
of making the wrong diagnosis and the consequent risk of postoperative
regret is therefore felt to be higher in adolescents than in adults, as a
consequence of the developmental phase itself. A more practical reason for
delaying the start of sex reassignment is that adolescents in many countries
are still legally dependent on the consent of their parents when deciding on
medical treatment. Even when the diagnostician and patient agree that the
SRS procedure should be started, parents may not give their consent.
Resistance from parents thus forms an extra complicating factor in the
treatment process and the clinician runs an increased risk of litigation.
There are, however, arguments in favor of
commencing the administration of hormones (and therefore the SRS procedure)
earlier than adulthood. Some adolescents, who have shown an extreme pattern
of cross-gender identification from their earliest years, suffer deeply from
the fact that they cannot be open about their gender feelings. As a
consequence of their gender identity disorder, they sometimes develop other
problems, which around the time of puberty increase and/or become
aggravated. Knowing that they will have to await treatment for many years
engenders feelings of hopelessness and slows down their social,
psychological, and intellectual development. They have to cope with adverse
consequences of living with a self-concept that is never socially
acknowledged or reinforced. In such cases, early treatment would prevent
much unnecessary, suffering.
Another argument for starting the sex
reassignment procedure in adolescents concerns their appearance. The
physical outcome of an early treatment can be expected to be more
satisfactory by comparison with starting later, especially, in
male-to-female patients. This is obviously an enormous and lifelong
advantage: instead of having to live with a deep voice and facial scarring
due to electrical epilation one can easily pass as a female. Ross and Need
(1989) found that postoperative psychopathology. was primarily associated
with factors that made it difficult for postoperative transsexuals to pass
as their new gender or that continued to remind them of their transsexualism.
Finally, on the basis of numerous follow-up
studies, one can conclude that unfavorable postoperative outcome seems to be
related to a late rather than an early start of the SRS procedure (for
reviews see Green and Fleming, 1990; Pfafflin and Junge, 1992). Age at
assessment also emerged as a factor differentiating two small groups of
male-to-female transsexuals with and without postoperative regrets (Lindemalm
et al., 1987).
With some rare exceptions (e.g., Dulcan and
Lee, 1984), clinicians have been hesitant to use forms of treatment other
than psychotherapy or environmental therapy for adolescent SRS applicants.
As mentioned earlier, a major problem is that it is not yet known for
certain who will and will not profit from early SRS. The ultimate answer to
the question of who would benefit from which treatment would come from
research in which adolescent applicants (with either more "fixed"
or more "fluid" gender identities) are randomly assigned to sex
reassignment or non-sex-reassignment treatment conditions, with adequate
operationalizations of gender identity and a long-term follow-up. For
ethical reasons such studies are obviously not possible.
Naturally, if a complete reversal of
extreme and lifelong cross-gender identity were possible by treatment
methods other than SRS, clinicians should refrain from SRS in adolescents,
and indeed in older patients. However, the few published case studies of
transsexuals (only some of them adolescents) who were "cured"
after psychotherapy (Barlow et al., 1973, 1979; Davenport and Harrison,
1977; Dellaert and Kunke, 1969; Kronberg et al., 1981; for a review see
Cohen-Kettenis and Kuiper, 1984) do not permit us to draw such conclusions,
for several reasons. First, operationalizations of gender identity differ
considerably from report to report.
Consequently, treatment success has been
evaluated on the basis of diverse and sometimes questionable criteria.
Second, few reports mention a long-term follow-up. Clinicians working with
transsexuals know that some applicants refrain from SRS, even without
psychotherapy, but, many years later, return to continue the procedure. So
even the claimed cures might in fact have been postponements of SRS.
Finally, the case studies usually describe patients who were highly
motivated to "change" their gender identity, a characteristic
rarely encountered in most of our applicants.
We believe that non-SRS treatment may be
helpful in cases of gender confusion or certain - mild - forms of gender
dysphoria. However, we doubt that the reported cases reflect a complete and
stable (re)establishment of a gender identity corresponding with genital sex
in persons with a lifelong and extreme cross-gender identity. Moreover,
despite many years of intensive psychotherapy, permanent gender identity
change is, even in the "milder" cases, not always achieved (Dulcan
and Lee, 1984; Lothstein, 1980). These considerations have led us and many
others to favor SRS as a treatment option for transsexuals. On the basis of
the above arguments we also try to explore carefully the treatment
boundaries for younger age groups.
In our hospital, children and adolescents
with gender identity disorder are seen at an outpatient gender identity
clinic. The recommended procedure in the Standards of Care of the Harry
Benjamin International Gender Dysphoria Association (Walker et al., 1985), a
professional organization in the field of transsexualism, is to arrive at a
diagnosis in two phases. In the first phase one gathers information
necessary for differentiating between the extreme gender identity disorder,
called transsexualism, and other types of gender disorders. Also, possible
risk factors for serious problems during the reassignment period and for
negative postoperative outcome are estimated.
At our clinic, in the first phase the child
and family are interviewed on the general and gender development of the
child, the way the parents have dealt with their child's gender deviancy,
and the family backgrounds of the parents themselves. By means of a
semistructured interview with the adolescent, a list of topics is discussed
(e.g., identification figures, relationship with same-sex and opposite-sex
parent, first conscious cross-gender feelings, emotional reaction of the
child to the maturation of the body). Many aspects of sexuality are included
in the discussion (such as sexual fantasies, sexual orientation, anxieties,
the meaning of cross-dressing, deviant sexual behavior). Current issues such
as school/career choice or school problems, relationship problems at home or
with peers, and romantic involvements are also addressed. During these
sessions several general aspects of the child's functioning (problem-solving
abilities, interpersonal functioning, reality testing, stability of the SRS
wish, etc.) can be observed, along with his or her gender role behavior.
Psychodiagnostic assessment is another element of the first phase. The
adolescent undergoes intelligence and personality testing and, if necessary,
neuropsychological testing. Our standard test battery also contains some
specific instruments, such as a body image scale (Lindgren and Pauly, 1975)
and a self-developed gender dysphoria scale (see below). The first phase may
take several weeks, months, or even years (Cohen-Kettenis, 1992, 1994).
Nontranssexual patients are not allowed to
start the second diagnostic phase or "real-life diagnostic test"
(Money and Ambinder, 1978). Instead, in cases of transvestitism, ego-dystonic
homosexuality, forms of gender confusion, etc., psychotherapy, family
therapy, or other forms of treatment are offered. In transsexual patients
the second diagnostic phase is started, if the risks of unfavorable
postoperative outcome are considered to be low. Because we are still in a
pioneering phase for adolescents, additional criteria are used for referral
to the second diagnostic phase. First, they must have shown a lifelong
extreme and complete crossgender identity/role. Around puberty these
feelings and behaviors must have become more rather than less pronounced.
Second, they must be psychologically stable (with the exception of depressed
feelings, which often are a consequence of their living in the unwanted
gender role) and function socially without problems (e.g., have a supportive
family, do well at school). If applicants meet the above requirements, they
are allowed to proceed to the second diagnostic phase, even if they are
younger than 18 years of age (but they must be older than 16). If they are
diagnosed transsexuals but do not meet the additional criteria, the second
diagnostic phase is postponed.
The second phase implies the start of the
real-life test, supported by a (partial) hormone treatment (Cohen-Kettenis,
1994). In Holland adolescents are referred for hormonal treatment (and
surgery) to members of the Free University Hospital Gender Team, which is
responsible for the treatment of 95% of the Dutch adult patients. Partial
hormone treatment blocks the action of sex steroids in a reversible way: the
male-to-female bodies do not masculinize any further, and the female-to-male
patients stop menstruating and sometimes experience a weakening of breast
tissue (Gooren and Delemarre-van de Waal, 1996). Full hormone treatment is
not reversible and masculinizes the female body, or feminizes the male body.
It is given before the age of 18 only when the patient has responded
favorably to the partial hormone treatment.
During the real-life test applicants have
to live full-time in the desired gender role. Thus they can discover whether
they are able to pass as someone of the opposite sex and experience all
advantages and disadvantages of the new situation. Depending on the
situation, the role change may occur gradually or at once. If the real-life
test is successfully passed, the patient is referred for surgery. Counting
from the start of the full cross-hormone treatment, the minimal duration of
the real-life test is 1 year for the FMs and 1.5 year for MFs. This
difference is due to the fact that the gender role change seems to have more
impact on the life of male-to-females (MFs) than on that of female-to-males
(FMs), and MFs therefore need more time to adjust to the new situation.
Because the very first patients going
through this procedure have experienced life in the desired gender situation
for quite some time, we decided to conduct a follow-up study. To our
knowledge no follow-up studies have ever been conducted on transsexuals
treated so early in life. We expected that the outcome of this young group
would be relatively favorable compared with the outcome among older groups.
In the first follow-up study among adult Dutch transsexuals (N=141) who had
undergone SRS (Cohen-Kettenis and Kuiper 1988; Kuiper and Cohen-Kettenis,
1988), SRS was found to solve gender problems but had not necessarily
alleviated other problems. Similar results have been found in non-Dutch
samples (for a review of 79 follow-up studies, see Pfafflin and Junge,
1992). The less positive results among adults may, in our view, be due to
the fact that they have had to live under adverse circumstances for a longer
period than individuals who are treated in adolescence.
The current study focused primarily on
postoperative gender feelings (regrets), gender functioning, and an
evaluation of the treatment. An alleviation of gender dysphoria can be
expected to be closely associated with improvement in other areas of life,
such as psychological, social, and sexual functioning. Although not
considered a primary outcome criterion, we also included these domains in
our study.
Method
Subjects
For the follow-up study the first 22
patients (15 FM and 7 MFs) who had undergone their last surgery at least 1
year before the start of the study were invited to participate. During the
period that these subjects applied for SRS, eight other applicants did not
receive the diagnosis of transsexualism and hence did not start the
real-life test. Three others were diagnosed as transsexuals, but their
real-life test was postponed because of severe concurring psychopathology
and/or adverse social circumstances. Two of the invited patients (1 FM and 1
MF) refused to be interviewed. One patient (an MF) did not respond to our
letters. This resulted in a posttreatment sample of 14 FMs and 5 MFs.
Instruments
IQ Tests.
IQ tests used were the WISC-R (van Haasen et al., 1986), WAIS (Stinissen et
al., 1970), and Groninger Intelligentie Test (Luteyn and van der Ploeg,
1983).
Gender Dysphoria Scale. The
Utrecht Gender Dysphoria Scale is a specially developed scale to measure
gender dysphoria. In the initial factor analyses of responses to this
measure, 12 of 32 items appeared to form a homogeneous scale: Cronbach's
alpha values were .80 for FMs (n = 56), .80 for MFs (n = 87), .81 for female
controls (n = 65), and .66 for male controls (n = 58). In a new sample of
202 SRS applicants who were either diagnosed transsexuals or gender-dysphoric
but not transsexual and who were participating in a 5-year prospective
study, the alpha values were .92 for male applicants and .78 for female
applicants (n = 82). The scale showed excellent discriminant validity v
between the transsexual and nontranssexual subjects in the first study (p
< .001) and between SRS applicants who were and were not referred for SRS
(p < .001) (Doorn et al., 1996). Examples of items are "I feel a
continuous desire to be treated as a man/woman" and "Every time
someone treats me as a woman/man 1 feel hurt."
Body Image Scale. A
body image scale (Lindgren and Pauly. 1975) that had been adapted for a
Dutch population (Kuiper. 1991) was used.
Personality Inventories.
The NVM is an 83-item shortened Dutch version of the Minnesota Multiphasic
Personality Inventory measuring the concepts of negativism, somatization,
shyness, psychopathology, and extroversion (Cronbach's alpha values in a
group of 894 psychiatric patients and 294 nonpatients ranged from .71 to
.86; validation studies are reported by Luteyn et al., 1980).
The Dutch Personality Questionnaire or
NPV is a widely used 133-item
personality questionnaire measuring feelings of inadequacy, social
inadequacy, rigidity, hostility, complacency, dominance, and self-esteem
(the median of the Cronbach's alpha values in 10 normative groups ranged
from .70 to .86; validation studies are reported by Luteyn et al., 1985).
Treatment Evaluation. Subjects
completed a semistructured oral interview with 27 questions about their
treatment outcome, their experiences during and after sex reassignment
(e.g., "In what ways do you feel hindered in your daily functioning as
a man/woman?"), their evaluation of the treatment (e.g., "If you
would have to start treatment with the knowledge you have now, which aspects
of the treatment should be different from what has happened to you?"),
feelings of regret (e.g., "How often do you contemplate living as a
man/woman again?"), and confidence in the possibility of
"passing" in the new gender role (e.g., "How often do you
feel insecure about your masculinity/femininity?") In the interview 46
questions were asked about the subjects' current life situation (e.g.,
work/education, financial situation, living circumstances, contacts with
family. and friends, partnership, sexuality, feelings of loneliness, alcohol
and drug abuse, and sleeping problems) (Doorn et al., 1996).
Subjects completed a questionnaire
concerning functionality of the vagina or penis and satisfaction with
surgical results (for MFs 3 items on breast enlargement, 10 on vaginoplasty;
for the FMs 5 items on breast removal, 4 on the neoscrotum, 7 on
phalloplasty) (Doorn et al., 1996).
Social Reactions Questionniare. A
20-item questionnaire assessed reactions of the social environment to the
transsexual (e.g., "People still call me 'sir,' even if I feel I look
good") (Doorn et al., 1996),
The IQ tests were administered before
treatment; the Utrecht Gender Dysphoria Scale, the body image scale, and the
personality questionnaires were completed before as well as after treatment
because within-subject changes were expected in these domains; and the other
instruments were used after treatment because they contain questions
regarding only the postoperative situation.
Procedure
Subjects were invited to come to the
Utrecht University Hospital or to combine a hormonal checkup at the Free
University of Amsterdam Hospital with the interview and testing. Each
session took 2 to 3 hours. To avoid socially desirable responses, the
subjects were seen by the second author, who is not involved in the
diagnosis or treatment of transsexuals.
Results
The mean age of the group was 17.5 years
(range 15 to 20) at the time of the pretest and 22.0 (range 19 to 27) at the
follow-up. Nine of the patients had started the "real-life test"
or second diagnostic phase, supported by hormone treatment, before the age
of 18. The mean elapsed time between the last operation and the time of the
follow-up interview was 2.6 years (range 1 to 5 years). The group's
pretreatment mean IQ score was 106 (SD = 14; range 71 to 127).
The group did not differ significantly from
a group of 23 diagnosed transsexuals in our clinic, who applied for SRS at a
later date and who were therefore not yet 1 year postoperative at the time
of our study, with respect to the following variables: age at application,
gender dysphoria score, intelligence, and scores on the personality rests (NVM
and NPV).
Gender Dysphoria
The difference between pre- and post test
score in gender dysphoria was highly significant (p < .001) (Table I).
The mean post test scores of the MF transsexuals were completely in the
range of the mean score of the aforementioned 87 female controls (mean =
15.7; SD = 5.4); likewise, the mean post test score of the FMs did not
differ significantly from the mean score of the aforementioned 58 male
controls (mean = 14.2; SD = 2.9). In addition, the MF group reported feeling
highly feminine and hardly masculine at all in response to questions on
masculinity and femininity, while almost exactly the reverse pattern was
found in the FM group (Fig. 1).
Fig 1 Masculinity
and feminity of female-to-male (solid bars) and male-to-female (striped
bars) transsexuals
None of the subjects expressed feelings of
regret about their decision to undergo SRS in response to any of several
questions regarding the topic, such as the following."Do you now have
any regrets with regard to your decision to live as someone of the opposite
sex?" "Did you ever have any regrets during or after the sex
reassignment procedure?" "Would you make the same decision again,
knowing what you now know about your sex reassignment?" "Did you
ever consider living in your original gender role again?" "Do you
sometimes live in your original gender role?" "Did you ever think,
during (after) the sex reassignment: I wish I had never started this?"
Body Satisfaction
With respect to their general appearance,
the majority of the group reported satisfaction: 100% of the MFs and 60% of
the FMs were satisfied, while 40% of the FMs were neutral. This is in line
with the interviewer's observation that it was difficult to discern any
signs of the biological sex. Satisfaction with primary and secondary sexual
characteristics after treatment increased significantly. Not included in
this analysis was an item on the (neo-) phallus (see below). For MFs, but
not for FMs, there was a slight increase in satisfaction with other physical
characteristics (Table 2).
Satisfaction with Surgery
For this group of FMs breast removal is
emotionally the most relevant type of surgery. This is because young FMs are
advised to postpone metaidoioplasty (transformation of the hypertrophic
clitoris into a micropenis) or phalloplasty (with or without construction of
a neoscrotum) because surgical techniques are steadily improving. Therefore
only one FM had, shortly before the interview, undergone a phalloplasty and
only two FMs had a neoscrotum. For the MFs, vaginoplasty is the most
important surgical intervention.
Forty percent of the FMs reported satisfaction
with their breast removal, 50% were moderately satisfied, and 10% were
dissatisfied with the result. Disappointment about the visibility of the
scars was the main reason for not being satisfied with breast removal.
Nevertheless, 80% did not have any problems with baring their chest when
swimming. Of the MFs, 60% expressed satisfaction with their vaginoplasty.
They felt their vaginas looked natural. Three MFs had experienced sexual
intercourse, without problems.
Occupational Status
Slightly fewer than half of the group (43%)
were studying (at a school for business administration or at university).
Thirty-six percent of the subjects had a job and 21% were unemployed. Of the
unemployed, two were not looking for a job.
Living Situation
Most subjects (79%) lived independently or
in student dormitories,14% of the subjects lived with their partner, and 7%
were living with their parents.
Relationships and Sexuality
The majority of the group (57%) had no
partner at the time of the interview or had never had one; 36% had a stable
relationship with a partner. One FM (7%) was having casual relationships
with several girlfriends. Of the subjects who at the time of the interview
had a sexual partner, 71% expressed satisfaction with their sex life, 14%
expressed a neutral view, and 14% were dissatisfied. Several FMs mentioned
that they found it difficult to live without a penis, especially at moments
when they did not know their potential sexual partner very well. Autosexual
behavior was not very frequent. Fifty percent of the subjects masturbated
less than once a month or never, 43% more than once a month. MFs generally
reported a decrease in frequency, while FMs reported no change or an
increase in frequency. Of the 13 subjects who were sexually active, 77%
regularly achieved orgasm.
Social Life and Social Contacts
The majority (89%) felt accepted and
supported in their new gender role by everyone they knew, while the
remainder (11%) felt accepted by several people. As a consequence of the sex
reassignment, 68% reported not having lost their relationship with any
family member or friend, while 21% had lost a relationship with just one
person. One MF had, before treatment, felt so isolated that she had
"little to lose." All except one subject had developed new
friendships since the beginning of the treatment. Parents and friends were
mentioned as the most important people to rely on in hard times (mother 71%,
father 43%, friends 50%). More superficial contacts such as with neighbors
or shopkeepers were either nonexistent/neutral (21%) or positive (79%). None
of the subjects had had experiences of being harassed. Most of the subjects
had been approached in a flirtatious manner, 58% regularly and 37%
sometimes. Not a single subject had been, since treatment, approached by
strangers as if they were someone of the biological sex.
Psychological Functioning
After treatment, a significant increase in
extroversion (NVM) (Table 3) was found, indicating a tendency to be more
active toward social contacts. When both pre- and posttest group means were
compared with Dutch normative data, all scores turned out to be within the
average range. We also found a significant increase in dominance and
self-esteem and a significant decrease in inadequacy (NPV) (Table 4). Again,
pre and posttest group means were all in the below average to average range,
when compared with Dutch norms.
General Functioning
Three patients seemed to have problems to
the point that they expressed only moderate satisfaction with their lives
and feelings of moderate happiness, in contrast to the rest of the group,
who felt satisfied or very satisfied and happy. The problems of two of these
three patients seemed to be primarily related to their unemployment. One FM
had dropped out of school and could not find a steady job. His girlfriend
had to support him financially, and he found this difficult to bear. The
other, a bright MF, had many diplomas, but poor social skills. She had
expected her diplomas to guarantee her a job in the world of business, but
she did not succeed in getting one. For this reason she had started a social
skills training and had hopes this would help her in her career. The third,
an FM had rather low self-esteem. Despite an absence of negative pre- and
posttreatment social experiences, good looks, and a steady girlfriend, he
had trouble overcoming, his uncertainties.
Some information, albeit not very
systematically gathered, is available concerning the three patients who
declined to participate in this study. All three patients still visit the
Free University Hospital Department of Andrology for their hormonal
checkups. Here we were informed that one FM had a partner with children from
a previous marriage and that he was unemployed. One MF had a job and was
involved in a steady relationship. The other MF was studying and had just
broken up with her boyfriend. On their visits to the hospital for hormonal
checkups, none of them had ever expressed regrets with regard to their SRS.
All three easily pass in their new gender role. Neither the endocrinologists
nor other Gender Team staff members believed these patients'
non-participation in the study was due to an unfavorable postoperative
outcome.
Discussion
In this adolescent group, 1 to 5 years after
surgery, sex reassignment seems to have been therapeutic and beneficial. SRS
has resolved the patients' gender identity problem and enabled them to live
in the new gender role in quite an inconspicuous way. Socially and
psychologically these adolescents do not seem to function very differently
from nontranssexual peers, perhaps with the exception of a greater
reluctance among those in the FM group to get involved in short-term or
incidental sexual encounters. Relief of gender dysphoria, however, does not
necessarily mean relief of unhappiness in general. In some cases, after SRS,
certain non-transsexualism related problems had disappeared, such as shyness
or bad school grades. But in other cases such changes had not occurred, or
the new situation had created new problems, such as (in the majority of the
FMs) living as a man without a penis. This condition may cause practical
problems, e.g., showering in a group setting after sports activities, and
emotional problems, e.g., being frustrated because of the impossibility of
having "real sex" with one's girlfriend. The extent to which such
unfavorable factors hamper postsurgical functioning depends largely on the
individual's psychological strength. That the group functioned quite well
from a psychological point of view suggests that they were capable of
handling their problems adequately.
In the previously mentioned study of adult
Dutch transsexuals who had undergone SRS (Kuiper and Cohen-Kettenis, 1988),
SRS was also found to be an effective treatment for transsexuals. Several
similar instruments were used in the two studies and all subjects were
treated in the same country. Therefore, data from our study are easier to
compare with data from this adult group than with data from non-Dutch
samples. Compared with the adult group, the adolescents function better
psychologically (Kuiper, 1991). In addition, they appear to have far fewer
social problems and they receive much more support from their families and
friends (Cohen-Kettenis and Kuiper, 1988). A comparison of the adults and
adolescents with respect to sexuality was difficult to make because the
majority. of the data from the adult transsexuals concern sexuality with a
partner, and this is not true of the adolescents.
Part of the adolescents' better functioning
might be due to the fact that they more easily pass in the desired gender
role, because of their convincing appearance. With the exception of one MF,
the voices of the MFs were not noticeably male sounding, and all MFs had
only sparse beard growth at the time of hormonal treatment. The early
antiandrogen treatment apparently had acted in a timely way to block the
facial hair growth and the lowering of the voice.
Another aspect of this relatively positive
outcome may be attributable to the criteria for treatment eligibility. As
explained in the introduction, additional criteria are applied for
applicants who want to start the real-life test before the age of 18. This
implies that those patients selected for early treatment not only are among
the best-functioning applicants, but probably they also belong to the
subtype of so-called "homosexual transsexuals" (that is,
individuals who are, before SRS, sexually attracted to same-sex partners)
(Blanchard, 1985). They are also referred to as "primary" or
"early-onset" transsexuals (Doorn et al., 1994; Person and Ovesey,
1974a,b). "Homosexual transsexuals" have been found, among other
things, to present earlier for treatment, to report more childhood
cross-gender identification,and to show less postoperative regrets than
"nonhomosexual transsexuals" (Blanchard, 1985, 1988; Blanchard et
al., 1989, Doorn et al., 1994). It is also possible that the biological
factors recently found to be associated with transsexualism are of greater
etiological significance in the earlyonset than in the late-onset group (Zhou
et al., 1995). Postoperative regrets in the nonhomosexual group (which
probably largely coincide with the late-onset group) are more likely because
they usually have a much longer and more inconsistent history of untreated
gender dysphoria, have for a longer period tried unsuccessfully to live in
the original gender role, and. as a consequence, have stronger ties to their
original role (as a partner, a father, or a colleague). Finally, most of the
transsexuals in our study were FMs. From other studies we know that FMs in
many respects fare better than MFs postoperatively (Pfafflin and Junge,
1992).
Sex reassignment of adolescent transsexuals
is a matter of considerable debate (Cohen-Kettenis, 1994, 1995; Meyenburg,
1994). On the basis of the findings of this study, it seems reasonable to
conclude that transsexuals treated during or shortly after adolescence will
not function worse postoperatively than transsexuals treated later. It is
true that they will have to confront difficulties during a vulnerable phase
of their lives. Not every transsexual adolescent will be capable of handling
these adequately. When diagnosing adolescent transsexuals one should
therefore be even more careful and when referring for hormone treatment one
should be more strict than one would be with adults. Thus, in
psychologically unstable applicants or applicants living 'In unfortunate
social/family circumstances, it seems sensible to address these factors
before proceeding to the real-life test.
Even adolescent applicants who are
functioning well will need a lot of guidance through the process of sex
reassignment. However, provided they manage to pass SRS without problems,
they have a lot to gain. They can catch up with their peers and devote their
attention to friendships, partnership, and career.
In the Netherlands medical health care and
legislation are relatively favorable for transsexuals: the treatment is paid
for by insurance companies or by national health insurance and a change of
birth certificate is legally possible. Both the general public and general
practitioners are well aware of the phenomenon of transsexualism and the
existence of specialized gender clinics. It is likely that in societies with
more negative attitudes toward the phenomenon, transsexuals will try to hide
their condition for a longer period or will psychologically be more damaged
at the moment of application. It is also likely that in such societies it is
harder to conduct studies similar to ours, because of a scarcity of suitable
candidates and a hesitance of clinicians to engage in non-established
treatment methods. But before arriving at definitive conclusions regarding
sex reassignment for adolescents, solid prospective studies should be
carried out with special attention for necessary and sufficient criteria for
SRS eligibility.
References
Barlow DH, Abel GG, Blanchard EB (1979),
Gender identity change in transsexuals: follow-up and replication. Arch
Gen Psychiatry 36:1001-1007
Barlow DH, Reynolds EJ, Agras WS (1973),
Gender identity change in a transsexual. Arch Gen Psychiatry
28:569-576
Blanchard R (1985), Research methods for
the typological study of gender disorders in males. In: Gender Dysphoria
Development, Research, Management, Steiner BW, ed. New York: Plenum
Blanchard R (1988), Nonhomosexual gender
dysphoria. J Sex Res 24:188-193
Blanchard R, Steiner BW, Clemmensen LH,
Dickey R (1989), Prediction of regrets in postoperative transsexuals. Can
] Psychiatry 34:43- 45
Cohen-Kettenis PT (1992), A gender clinic
for children and adolescents: the Dutch model. Proceedings of the
conference on Gender Identity and Development in Childhood and Adolescence,
London
Cohen-Kettenis PT (1994), Die Behandlung
von Kindern und Jugendliche mit Geslechtsidentitatssiorungen an die
Universitat Utrecht. Z Sexualforsch 7:321329
Cohen-Kettenis PT (1995), Replik auf Bernd
Meyenburgs "Kritik der hormonellen Behandlung Jugendlicher mit
Geslechtsidentitatssiorungen." Z Sexualforsch 8:165-167
Cohen-Kettenis PT, Kuiper AJ (1984),
Transseksualiteit en psychotherapie. Tijdschr Psychoth 3:153-166
Cohen-Kettenis PT, Kuiper AJ (1988), Social
aspects of sex reassignment surgery. In: Sexology, Eicher W, Kockott
G, eds. Berlin: Springer-Verlag, pp 187-191
Davenport CW, Harrison SI (1977). Gender
identity change in a female adolescent transsexual. Arch Sex Behav
4:327-339
Dellaert T, Kunke T (1969), Investigations
on a case of male transsexualism. Psychother Psychosom 17: 89-107
Doorn CD, Kuiper AJ, Verschoor AM, Cohen-Kettenis
PT (1996), Het verloop van de geslacbtsaanpassing een 5-jarige prospectieve
studie (The course of sex reassignment: a 5-Year prospective study). Rapport
voor de Nederlandse Ziekenfondsraad (Report for the Dutch National Health
Council Doorn CD, Poortinga J, Verschoor AM (1994), Cross-gender identity in
transvestites and male transsexuals. Arch Sex Behav 23:185-201
Dulcan M K, Lee PA (1984), Transsexualism
in the adolescent girl. J Am Acad Child Psychiatry 23:354-361
Gooren LJG, Delemarre-van de Waal H (1996),
The
feasibility of endocrine interventions in juvenile transsexuals. J
Psychol Hum Sex 8:69-74
Green R (1987), The "Sissy boy
Syndrome" and the Development of Homosexuality, New Haven. CT: Yale
University Press
Green R, Fleming DT (1990). Transsexual
surgery follow-up: status in the 1990s. Annu Rev Sex Re.1;163-174
Kronberg J, Tyano S, Apter A, Wiisenbeek H
(1981). Treatment of transsexualism in adolescence. J Adolesc
4:177-185
Kuiper M (1991), Transsexualiteit
evaluatie van de ge slachtsaanpassende behandeling. Amsterdam: Free
University Press
Kuiper A]. Cohen-Ketrenis PT (1988). Sex
reassignment surgery: a study of 141 Dutch transsexuals. Arch Sex Behav
17:439-457
Lindemalm G, Korlin D, Uddenberg N (1987).
Prognostic factors vs outcome in male-to-female Transsexualism: a follow up
of 13 cases. Acta Psychiatr Scand 74:268-274
Lindgren T, Pauly I (1975). A body image
scale for evaluatingtranssexuals. Arch Sex Behav 4:639-656
Lothstein LM (1980). The adolescent gender
dysphoric patient: an approach to treatment and management. J Pediatr
Psychol 5:93-109
Luteyn F, Kok AR, van der Ploeg FAE (1980).
NVM. Nederlandse Verkorte MMPI. Handlesding. Lisse: Swetz en
Zeitlinger
Luteyn F, Starren J, van Dijk H (1985).
Handleiding bij de NPV . Lisse: Swetz en Zeitlinger
Luteyn F, van der Ploeg FAE (1983).
Handleiding Groninger Intelligentie Test (GIT). Lisse: Swetz en
Zeitlinger
Meyenburg B (1994). Kritik der hormonellen
Behandlung Jugendlicher mir Geslechtsidentitatssforungen. Z Sexualforsch 7:343-349
Money J, Ambinder R (1978). Two-Year,
real-life diagnostic test: rehabilitation versus cure. In Controversy in Psychiatry.
Brady JP, Brodie HKH, eds. Philadelphia: Saunders. pp 833-845
Person E, 0vesey I (1974a). The transsexual
syndrome in males: I. Primary transsexualism. Am J Psychother 28:4-29
Person E, 0vesey I (1974b). The transsexual
syndrome in males: II. Secondary transsexualism. Am J Psychother
28:174-193
Pfafflin F, Junge A (1992).
Geschlechtsumwandlung: Abhandlungen zur .transsexualitat. Stuttgart:
Schartauer
Ross MW, Need JA (1989). Effects of
adequacy. of gender reassignment surgery on psychological adjustment: a
follow-up of fourteen male-to-female patients. Arch Sex Behav
18:145-153
Stinissen J, Willems PJ, Coetsier P,
Hulsman WLL (1970). Handleiding WAIS. Nederlandstalige bewerking. Amsterdam:
Swetz en Zeitlinger van Haasen PP, de Bruyn EEJ, Pijl YJ et al (1986),
Wechsler Intelligence Scale for Children-Revised. Nederlandstalige
uitgave. Lisse: Swetz en Zeirlinger
Walker PA, Berger JC, Green R, Laub DR,
Reynolds CL, Wollman L (1985), Standards of care: the hormonal and surgical
sex reassignment of gender dysphoric patients. Arch Sex Behav
14:79-90
Zhou J, Hoffman MA, Gooren LJG, Swaab DF
(1995). A sex difference in the human brain and its relation to
transsexuality. Nature 378:68-70
Zucker KJ, Green R (1992). Psychosexual
disorders in children and adolescents. J Child Psychol Psychiatry 33:107-151
Zuger B (1984). Early effeminate behavior
in boys: outcome and significance for homosexuality. J Nerv Ment Dis 172:90-97
Citation: J Am Acad
Child Adolesc Psychiatry 1997 Feb;36(2):263-71 an article published on the
Internet <http://www.antijen.org/cohen.html>
|
