No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Acute symbiotic psychosis in a postoperative transsexual
Archives of Sexual Behavior
Abstract
An unexpected complication of sex-reassignment surgery in a 23-year-old male-to-female transsexual is presented. Having been periodically depressed but never psychotic before surgery, the patient experienced an acute decompensation 3 days after operation. Symptoms of this time-limited illness included hallucinations and wish-fulfilling delusions, but most prominent was the demand to be in continuous contact with other people. Historical data revealed a symbiotic relationship with the grandmother ending precipitously with her death when the patient was 6. It is hypothesized that the unresolved grief reappeared after the surgery, owing to the unconscious linkage between becoming "female" and regaining the lost symbiotic object. Recompensation, possibly through the use of another person as a transitional object, was noted during the illness. This was felt to be a repetition of the pattern of reaction to previous losses.
... Decisions about GA treatment were considered thoroughly, there were no regrets, and adherence to treatment was high. Our results do not support reports that the effects of hormonal 19,20 or surgical 43,44 GA interventions may trigger psychosis. The one psychotic decompensation that showed a relationship with the GA trajectory occurred during a prolonged diagnostic phase in which the individual experienced distress and uncertainty. ...
Purpose:
Controversy exists as to if, and when, gender affirmative (GA) treatment should be offered to individuals with gender dysphoria (GD) and co-existing psychosis. Concerns exist regarding a high risk of misdiagnosing, regret afterward due to impulsive decision making, and deterioration of psychotic symptoms. This case series aims at extending the sparse literature on GA treatment in this population by identifying challenges in diagnosis and treatment and offering recommendations to overcome them.
Case series:
The authors present case descriptions of two transgender men and two transgender women in the age range of 29-57 years with a diagnosis of GD and a schizophrenia-related diagnosis. All had undergone GA treatment with a minimum follow-up of 3 years. The gender diagnosis was complicated by the fact that feelings of GD were only shared after the onset of psychosis, and GA treatment was hampered by the persistence of mild psychotic symptoms despite antipsychotic treatment. Close communication with the psychosis treating clinicians proved useful to address these problems. GA treatment was paralleled by a stabilization of psychotic symptoms, and adherence to and satisfaction with the therapy was high.
Conclusion:
These case examples show that GA treatment is possible and safe in this vulnerable population.
Theoretical accounts of the origins of gender identity disturbance are reviewed and then followed by a description of the establishment of a child and adolescent gender identity clinic. Clinical impressions of 16 gender disturbed patients are presented and the position is taken that most patients manifested a confused, as opposed to fixed, core gender identity.
Other than somewhat improved anatomical and physiological understanding, in the areas of human sexuality medicine and psychiatry have not progressed much beyond the 19th century situation described by Duffy. Improved behavioral science research has overturned most traditional medico-psychiatric theories of sexual disorder (see e.g. [6, 7, 49]). Psychiatrists squabble over theories of sexual disorder in debates marked by a near total absence of scientifically credible non-anecdotal evidence. Bleeding, purging, sweating, and the like now take the form of catharsis on the therapist’s couch, the bizarre cross-dressing therapies which, although psychologically debilitating [61], have become common in the treatment of gender dysphoria, etc. The inclusion of the paraphilias in DSM-III [3] is supported only by anecdotal or wishful evidence that fails to meet minimal scientific evidential standards [53, 54, 56]. The efficacy of psychotherapeutic techniques is unknown, and problems of control virtually preclude any objective empirical evaluation [26]. What would count as a cure is hopelessly obscure [52].
The findings of this paper are based on a 3-year study at the Gender Identiy Clinic of University Hospitals of Cleveland, involving 16 patients who were sexually revised (SR) from a total of 125 applicants. Three of these patients were provided second-stage surgeries which were begun elsewhere. The paper addresses some of the major problems of the SR patients' pre- and postsurgical experience. Specifically, a) evidence is provided to suggest the existence of a well defined preoperative syndrome which often affects the postoperative course of recovery which may lead to a clinical state of depression; b) the problems and process of the medical team in the treatment of the SR patient are discussed; and c) a modified version of Janis' counseling model for the high risk presurgical patient (to be employed with the preoperative SR patient) is introduced. These important but often neglected topics help us to understand some of the psychiatric management problems in the pre- and postoperative SR patient, while also pointing to some of the difficulties researchers have had in providing follow-up studies with this patient population.
The psychological functioning of male heterosexuals, transvestites, preoperative transsexuals and postoperative transsexuals was assessed. The groups represented a gradient of progressive feminization which showed progressive levels of psychological dysfunction. The data indicated that the transsexuals studied were indicative of a select group demonstrating profound psychological dysfunction. The study contributes to the recent literature, which indicates that sex reassignment surgery for this group is not the treatment of choice. Criteria for projecting postoperative outcome are outlined which can be utilized to direct gender dysphoria patients to alternate treatments.
It was hypothesized that male transsexuals manifest a character structure consistent with Kernberg's criteria for borderline personality organization. Exploring this hypothesis, Kernberg's criteria for borderline personality organization were operationalized using Rorschach measures. The following variables were examined: aggression (Holt System Aggressive Content Section), object relations (Urist's Mutuality of Autonomy Scale), reality testing (Exner System X + %), and self/object differentiation (Exner System Special Scorings). A group of male college students, a group of male borderlines, and a group of male transsexuals were compared on the above variables. Compared to the normals, the transsexuals and borderlines displayed significantly more intense levels of aggression, a lower level of object relations, poorer reality testing, and impaired boundary differentiation. The transsexuals and borderlines did not differ significantly. The results were taken as suggesting that male gender dysphorics may be a sub-group of the wider borderline diagnostic category.
Transsexualism involves incongruity between anatomy and gender identity in biological normal persons. The literature in this area indicates controversy in diagnosis and treatment. Current guidelines for assessment and treatment selection are critically reviewed. Outcome data suggest that sex reassignment surgery is variably effective and potentially deleterious. Child and adult interventions may be more viable than previously assumed. Recommendations for research include systematic follow-up, longitudinal studies of gender-deviant children, and studies of psychopathology. Until rigorous outcome data are available, return to a conservative position on sex reassignment, using highly exclusive diagnostic guidelines and restrictive selection criteria, is advocated.
This paper presents the psychiatric diagnostic findings on 51 patients who requested Sex Reassignment Surgery. The biologic females, as a group, were significantly healthier than the males. Ninety-two percent of the males and 58% of the females had psychiatric diagnoses, apart from gender dysphoria. Most of the abnormalities in both groups were character disorders; eight percent of the patients, however, were schizophrenic. Psychometric evaluation suggested that approximately one-half of the patients had more serious disorders than were indicated during clinical evaluation. The initial and ongoing diagnostic processes are helpful in the pre- and postoperative management of patients with gender dysphoria.
Fifteen years ago the author reviewed the world literature on male transsexualism (Pauly, 1965). Subsequently he summarized the results of sex reassignment surgery for male and female transsexuals (Pauly, 1968), and reviewed the literature on female transsexualism (Pauly, 1974). Very recently, Meyer and Reter (1979) concluded that 'sex reassignment surgery confers no objective advantage in terms of social rehabilitation' as compared with a group of individuals who sought sex reassignment but remained unoperated upon at follow-up. Both groups improved over time and led the Johns Hopkins Gender Identity Clinic to conclude that sex reassignment surgery would no longer be offered there. This report, and other non-surgical, psychotherapeutic approaches to gender dysphoric patients (Barlow et al., 1973; Barlow et al., 1979; Lothstein and Levine, 1980) call into question the justification for sex reassignment surgery. Therefore, it becomes important to update the results of sex reassignment surgery for transsexuals. Data on 283 male to female transsexuals and 83 female to male transsexuals are presented.
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.
Professional, patient and media forces tend to oversimplify the complexity of the gender dysphoria syndrome. Because sex reassignment surgery may be helpful to some patients with the syndrome and harmful to others, mental health professionals need to competently perform differential diagnoses of both the gender disorder and the associated psychopathologies. This frequently involves distinctions between subtle forms of psychosis, character pathologies of varying severity, and major developmental problems. Surgery should not be considered the only, or the best, treatment for the syndrome. Contrary to popular belief, psychotherapy can help many patients, especially those with secondary gender dysphoria.
The authors studied the incidence of parental loss among 163 gender-disordered patients and an equal number of psychiatric control patients. An unusually high number of gender-disordered patients had lost their fathers, particularly during adolescence and early adulthood. Many of these patients showed shifts in gender identity in the year after loss, and during that period many requested surgical sex reassignment for the first time. Changes in the patient's relationship with the remaining parent and experiences related to loss of the father are discussed.
Two groups of patients served as subjects for the study. Group I consisted of seven biological males (three whites and four blacks) who received surgery before the organization of the CWRU Gender Identity Clinic; Group II consisted of 14 postsurgical patients (eight biological males, two white, six black; and six white biological females) from the CWRU Gender Identity Clinic. A nine-page, 59-item questionnaire was constructed to collect systematic follow-up data for Group II. Data were collected up to 2 years postsurgery at varying intervals, measuring the sexual, psychological, environmental, economic, parental, family, medical, and social adjustment and functioning of each patient. While surgery provided in the context of a comprehensive Gender Identity Clinic program may lead to moderate social-sexual gains, researchers must begin to focus on the psychological problems not broached by surgery. The recommendation that psychotherapy be attempted with these patients (both pre- and postsurgery) is an important outgrowth of the study. Moreover, the need for a more systematic approach to follow-up, including the use of standardized interviews and clinical assessment tools and adequate control groups, is discussed.
CONSIDERS SEX A BIOLOGICAL ASCRIPTION WHEREAS GENDER IS THE RESULT OF PSYCHOLOGICAL FACTORS. DATA ARE PRESENTED ON PERSONS WITH CROSS-GENDER PATHOLOGY INCLUDING TRANSVESTISM AND TRANSSEXUALISM. PSYCHOANALYTICALLY ORIENTED IN THE INTERESTS OF BETTER TREATMENT OF PATIENTS WITH GENDER DISTURBANCES. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Presentation to AMA Convention
- L Ovesey
- E Pearson