Sexual and Physical Health After Sex Reassignment Surgery

Abstract

A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male) post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome. Relatively few and minor morbidities were observed in our group of patients, and they were mostly reversible with appropriate treatment. A trend toward more general health problems in male-to-females was seen, possibly explained by older age and smoking habits. Although all male-to-females, treated with estrogens continuously, had total testosterone levels within the normal female range because of estrogen effects on sex hormone binding globulin, only 32.1% reached normal free testosterone levels. After SRS, the transsexual person's expectations were met at an emotional and social level, but less so at the physical and sexual level even though a large number of transsexuals (80%) reported improvement of their sexuality. The female-to-males masturbated significantly more frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement, and more easily reaching orgasm was seen in the female-to-male group. The majority of participants reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported the secretion of a vaginal fluid during sexual excitation, originating from the Cowper's glands, left in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more realized (compared to those without), but pain during intercourse was more often reported.

Full text

Archives of Sexual Behavior, Vol. 34, No. 6, December 2005, pp. 679–690 (
C

2005)
DOI: 10.1007/s10508-005-7926-5
Sexual and Physical Health After Sex Reassignment Surgery
Griet De Cuypere, M.D.,
1,7
Guy T’Sjoen, M.D.,
2
Ruth Beerten, M.Sc.,
1,3
Gennaro Selvaggi, M.D.,
4
Petra De Sutter, M.D., Ph.D.,
5
Piet Hoebeke, M.D., Ph.D.,
6
Stan Monstrey, M.D., Ph.D.,
4
Alfons Vansteenwegen, Ph.D.,
3
and Robert Rubens, M.D., M.Sc.
1,2
Received April 2, 2004; revision received September 2, 2004; accepted December 2, 2004
A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male)
post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome.
Relatively few and minor morbidities were observed in our group of patients, and they were mostly
reversible with appropriate treatment. A trend toward more general health problems in male-to-
females was seen, possibly explained by older age and smoking habits. Although all male-to-females,
treated with estrogens continuously, had total testosterone levels within the normal female range
because of estrogen effects on sex hormone binding globulin, only 32.1% reached normal free
testosterone levels. After SRS, the transsexual person’s expectations were met at an emotional and
social level, but less so at the physical and sexual level even though a large number of transsexuals
(80%) reported improvement of their sexuality. The female-to-males masturbated significantly more
frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement,
and more easily reaching orgasm was seen in the female-to-male group. The majority of participants
reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and
more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported
the secretion of a vaginal fluid during sexual excitation, originating from the Cowper’s glands, left
in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more
realized (compared to those without), but pain during intercourse was more often reported.
KEY WORDS: transsexualism; gender identity disorder; sexual functioning; orgasm; sex reassignment surgery.
INTRODUCTION
Hormonal treatment and sex reassignment surgery
(SRS) are both considered the treatment of choice for
1
Department of Sexology and Gender Problems, University Hospital
Ghent, Ghent, Belgium.
2
Department of Endocrinology, University Hospital Ghent, Ghent,
Belgium.
3
Institute of Family and Sexuality Studies, KU Leuven, Belgium.
4
Department of Plastic Surgery, University Hospital Ghent, Ghent,
Belgium.
5
Department of Gynaecology, University Hospital Ghent, Ghent,
Belgium.
6
Department of Urology, University Hospital Ghent, Ghent, Belgium.
7
To whom correspondence should be addressed at Department of Sex-
ology and Gender Problems, University Hospital Ghent, De Pintelaan
185, B-9000 Ghent, Belgium; e-mail: griet.decuypere@uzgent.be.
transsexual persons. Evaluations of these treatments
are still needed. In this study, a long-term follow-up
investigation of 55 patients post-SRS was carried out
to evaluate sexual and general health outcome. Since
the start of the multidisciplinary Ghent Genderteam, we
have always used a dual-phase hormonal schedule, with
a first reversible part where sex specific features are
suppressed, together with starting the real-life test. In the
second part, cross-sex hormones were given, resulting
in irreversible feminization and masculinization. In some
centers, spironolactone (Prior, Vigna, & Watson, 1989) or
cyproterone acetate (van Kesteren, Asscheman, Megens,
& Gooren,1997) are routinely added to estrogen treatment
at the beginning of the hormonal treatment, whereas in
other centers cross-sex hormonal treatment is started as
a unique treatment. No randomized studies are as yet
679
0004-0002/05/1200-0679/0
C

2005 Springer Science+Business Media, Inc.

680 De Cuypere et al.
available to determine the optimal dosage of hormones or
the preferred regimen for the treatment of transsexuals.
A variety of compounds are used in high dosages,
increasing the risk of side effects (Asscheman & Gooren,
1992). The Amsterdam group reported a high incidence
of depressive mood changes, hyperprolactinaemia, and
thromboembolic events, compared to a normal population
(Asscheman, Gooren, & Eklund, 1989).
The first aim of this study was therefore to evaluate
the long-term safety of the Ghent hormonal treatment
regimen. Secondly, where most studies on transsexual
people focus on long-term psychological, surgical, and
physical health (Eldh, Berg, & Gustafsson, 1997; Pf
¨
afflin
& Junge, 1998), a surprisingly small number of studies
have focused on the sexual life of postoperative transsex-
uals, although adequate sexual functioning is universally
acknowledged as an important component of mental
health. Little attention has been given to this subject and,
indeed, the vast majority of follow-up studies investigated
the sexual functioning only as part of the psychological
or the surgical outcome.
Although there is general agreement that female-
to-male transsexuals are mostly attracted to females,
discordant findings where female-to-male transsexuals
were attracted to men have been reported by Chivers
and Bailey (2000), indicating that this group may not
be homogenous. Also Coleman, Bockting, & Gooren
(1993) reported on nine female-to-male transsexuals
sexually attracted to men. The group of male-to-females
is known to be more heterogeneous and figures vary from
23 to 58% of male-to-females attracted to women (De
Cuypere, Jannes, & Rubens, 1995; Smith, 2002). Until
recently, it was also assumed that the sexual orientation
of transsexual people did not change during transition.
Daskalos (1998) reported on 6 male-to-females (out of 20)
who described that their sexual orientation had switched
from attraction to females to attraction to males. The
respondents themselves explained these changes as part of
their emerging female gender identity. Before SRS, they
had tended to conform as “normal males,” which implied
being attracted to women. Most male-to-females look for
a new partner after SRS, whereas female-to-males tend to
remain with the same partner (Bodlund & Kullgren, 1996;
K
¨
ockott & Fahrner, 1988; Steiner & Bernstein, 1981). It
is remarked (Eldh et al., 1997; K
¨
ockott & Fahrner, 1988;
Pf
¨
afflin & Junge, 1990) that not all transsexual people
wish to inform their new partners about their transsexual
past and more male-to-females (up to one-third) than
female-to-males manage to keep silent about their past.
Few studies deal with the topic of masturbation.
Female-to-males are supposed to masturbate more fre-
quently than male-to-females and more frequently than
before SRS (Kuiper, 1991; Smith, 2002; Sorensen, 1981a,
1981b). The data about reaching orgasm after SRS are
very inconsistent throughout the literature. Lindemalm,
Korlin, and Uddenberg (1986) reported that 54% of male-
to-females were not able to reach orgasm. Blanchard,
Legault, and Lindsay (1987) described that the capacity
for orgasm in male-to-females decreased after SRS, which
is contradicted by the data by Kuiper (1991). Pf
¨
afflin and
Junge (1990) and Eicher, Schmitt, and Berger (1991)
described that 70–80% of the male-to-females were
capable of orgasm even during intravaginal intercourse.
Although not all postoperative transsexual people are
orgasmic, there is a much wider sexual satisfaction after
transition. It is possible to change one’s body image and be
sexually satisfied, despite inadequate sexual functioning
(Lief & Hubschman, 1993). Recent studies show good
genital sensitivity, probably as a result of advances in
surgical techniques where, for example, in phalloplasty
one forearm nerve is anastomosed to one of the dorsal
clitoral nerves (Monstrey et al., 2001).
Our center is presently among those with extensive
experience in phalloplasty (P.H and S.M). This gives
us the opportunity to focus on the sexual consequences
of this particular surgical intervention. As the number
of male-to-females and female-to-males was similar and
both groups had followed a similar procedure—screened
and treated by the same professionals—we were able
to compare the male-to-female and the female-to-male
transsexuals for different topics of sexual health. Finally,
this descriptive study also focused on lubrication during
sexual arousal, as some postoperative male-to-female
patients spontaneously mentioned this.
METHOD
Participants
In 1985, the Ghent Genderteam started treating
persons with gender identity disorder using a multidisci-
plinary approach. The first surgery (a vaginoplasty) took
place in 1988. Our surgeons have offered phalloplasty
since 1993.
A total of 107 Dutch speaking patients who under-
went SRS between 1986 and 2001 were contacted to
participate in this study. We selected only Dutch speaking
patients because they followed the same treatment proce-
dure and also because of practical reasons (distance from
the hospital and standardization of translated question-
naires). A minimum delay period of 1 year after SRS was
respected. This year is often called the honeymoon period
and therefore does not represent a realistic picture of

Health After Sex Reassignment Surgery 681
long-term emotional stability, sexual, and psychological
status. Of the 107 patients who were eligible for the
study, 30 could not be contacted (in majority male-to-
females) and 15 (mainly female-to-males) declined to
participate. Seven patients wanted to cooperate only if
it did not involve attending the hospital visit. The other 55
participants (32 male-to-females and 23 female-to-males)
completed the questionnaires and were subsequently
interviewed on a face-to-face basis by a sexologist (R.B.),
endocrinologist (G.T.), and examined by a surgeon (G.S.).
None of the researchers had been involved in the initial
assessment or treatment of the patients. All of the male-
to-females underwent vaginoplasty, 21 female-to-males
had a phalloplasty whereas 2 female-to-males had not
yet made up their minds about having one. Most of
the female-to-males chose to undergo a phalloplasty,
as the outcome is mostly very satisfying. A total of
28 male-to-female transsexuals and 20 female-to-male
patients agreed to additional blood testing (examination of
hormonal parameters, lipids, glucose, and liver and renal
function).
At our center, when the transsexual patient has
passed the first diagnostic phase, she/he is referred to
the endocrinologist for a general health survey and
hormonal therapy. The treatment regimen used at our
center is somewhat particular. The transsexual patient
will first undergo a (reversible) chemical castration for
approximately 1 year, before receiving hormones of the
opposite sex, after which irreversible changes occur.
The first reversible phase includes anti-androgens (e.g.,
cyproterone acetate 50–100 mg daily) in male-to-female
transsexuals and progestins (e.g., lynestrenol 5 mg daily)
in female-to-male transsexuals. The reversible phase is
considered an important phase of the real-life test, in
which gender-specific features, such as erections or men-
strual bleeding, are suppressed. The dual-phase hormonal
therapy gives the patient more opportunity for reflection
and adaptation to the new sex. In the second part, cross-
sex hormones are given for 1 year, resulting in irreversible
feminization or masculinization. The administration of
these hormones may lead to side effects, all the more
so because the cross-sex hormones are administered
life-long (Moore, Wisniewski, & Dobs, 2003). Surgical
sex correction is considered after 2 years of hormonal
therapy during which the patient has to pass the real-life
test or experience: the patient has to live in the opposite
sex role within her/his own personal and professional
life when cross-sex hormones are started. Most gender
teams have adopted the Standards of Care of the Harry
Benjamin International Gender Dysphoria Association,
which have clearly defined the indications and methods
for hormonal and sex reassignment surgery of gender
dysphoric patients (Meyer et al., 2001). The policy of our
Genderteam implies a longer waiting period for cross-
sex hormones compared to other centers, increasing the
risk of self-medication. However, explanation of the ra-
tionale behind the protocol usually prevents patients from
doing so.
The male-to-females were significantly older than
the female-to-males at the time of SRS, t(52) =−4.7, p <
.001, as well as at the time of research, t(53) =−3.6, p =
.001 (Table I). The mean follow-up period was different
for both groups, with a longer period for the female-to-
males, t(52) = 2.6, p = .013. Regarding the duration of
relationship, no significant difference between the two
groups was found. For both male-to-females and female-
to-males, there were no significant differences in age of
the patient and their respective partners. A homosexual
Table I. Description of Study Participants
Male-to-female Female-to-male
(n = 32) (n = 23)
MSDMSDtor χ
2
p
Age at time of SRS (years) 37.8 8.9 26.9 7.2 −4.7 <.001
Age at time of interview (years) 41.5 9.1 33.2 7.0 −3.6 .001
Duration of follow-up period (years) 3.8 2.7 6.2 4.2 2.6 .013
Duration of relationship (years) 5.1 5.1 5.2 5.2 <1 ns
Age of partner (years) 41.1 10.0 29.0 3.5 −3.1 .006
Height (m) 1.76 0.08 1.65 0.07 −4.8 <.001
Weight (kg) 73.4 13.2 63.9 9.0 −2.8 .008
Body Mass Index (kg/m
2
) 23.7 3.9 23.4 2.8 <1 ns
Alcohol intake on a weekend/nonworking day (g) 43.4 40.6 45.9 37.6 <1 ns
Alcohol intake on a working day (g) 26.3 10.0 26.5 17.2 <1 ns
Active smoking (n) 15 46.9% 4 17.4% 7.3 .026
Homosexual orientation (n) 18 56.3% 21 91.3% 8.1 .004

682 De Cuypere et al.
orientation was reported in 56.3% of male-to-females
and in 91.3% of female-to-males, χ
2
(1,n = 54) = 6.12,
p = .013. At the time of the interview, there was a
significant difference in age between nonhomosexual
and homosexual male-to-females (45.6 and 37.5 years,
respectively, t (31) =−2.804, p = .009.
All participants gave written informed consent for
participation in this study, approved by the Ethical
Committee of the Ghent University Hospital.
Measures
General Health
As sex steroid treatment is known to be associated
with several side effects, selected post-surgery data were
collected from this sample. Current and past hormonal
treatment, smoking and drinking habits, other medical
treatment, and general health issues, such as thrombogenic
accidents, heart conditions, hypertension, depression,
hyperprolactinaemia, thyroid problems, hyperlipidemia,
liver function problems, and osteoporosis, were ad-
dressed. This information was discussed in detail with
the patient, and confirmed by physical examination (e.g.,
blood pressure), laboratory assessment (e.g., prolactin
levels), review of medication intake, and systematic
review of the medical records. It is, however, possible that
patients gave incorrect information about, for example,
use of alcohol and tobacco to present themselves favorably
to their clinicians.
Biographical Questionnaire for Transsexuals
and Transvestites
Data were derived from an extensive, structured
interview (BVT, Biographical Questionnaire for Trans-
sexuals and Transvestites; Verschoor & Poortinga, 1988)
in which each question has fixed response categories.
This interview is used in all Dutch gender clinics as
part of the intake procedure at the initial diagnos-
tic assessment (Doorn, Poortinga, & Verschoor, 1994).
This descriptive questionnaire contains items referring
to sociodemographic information, gender development
during adolescence and adulthood, preadolescent gender
behavior, transvestite practice, sexuality, and medical
antecedents (250 items). Selected items were reapplied in
this study: stable sexual relationship (e.g., “Do you have
a stable sexual relationship?”), sex of the partner, sexual
satisfaction with the partner, frequency of orgasm (during
intercourse), frequency of masturbation, and frequency of
sexual arousal. In this way, pre- and posttreatment data
were obtained. Items as start of relationship, duration
of relationship, age of partner, sexual satisfaction in
general, improvement/worsening of sex life, frequency
of orgasm during masturbation, change in orgasmic
feelings, lubrication, meeting the expectation of SRS, pain
during intercourse, and general satisfaction describing
the postsurgical condition were incorporated in a self-
developed questionnaire with fixed response categories.
If applicable, the categories were quantified from 1 =
never to 4 = (almost) always.
Body Image Scale
The Body Image Scale (BIS; Lindgren & Pauly,
1975), adapted for a Dutch sample by Kuiper (1991),
was used. This scale consists of 30 items divided into
three subscales: primary, secondary, and neutral sexual
characteristics, with higher scores representing more dis-
satisfaction (5-point category). The internal consistency
was good for the versions for both female-to-male and
male-to-female transsexuals, with Cronbach’s α = .88
and .87, respectively.
Satisfaction with the Surgical Results
The satisfaction with mastectomy and phalloplasty
or mammoplasty and vaginoplasty was evaluated by the
patient on a 5-point rating scale (1 = very unsatisfied to
5 = very satisfied).
Hormone Assays
Following the personal interviews, venous blood was
obtained between 08:00 and 12:00 hr after an overnight
fast, but because of practical reasons, regardless of the
timing of the last administration of the hormonal treat-
ment. This was important in female-to-males in regard
to long-acting intramuscular testosterone administration.
The sex steroid levels were measured in each participant
in order to evaluate these hormones that may affect
features of virilization or feminization. The gonadotropin
levels were measured to detect more subtle variations in
the hypothalamo–pituitary–gonadal axis. To avoid effects
of seasonal variation, blood collection was completed
in a period of 2 months. Commercial kits for radio
immunoassay (RIA) were used to determine the serum
concentrations of testosterone (Medgenix Diagnostics,
Fleurus, Belgium) and estradiol (Incstar, Stillwater, MM,
USA); commercial kits for immuradiometric assays were
used for determinations of serum sex hormone binding
globulin (SHBG; Orion Diagnostica, Espoo, Finland),

Health After Sex Reassignment Surgery 683
Dehydroepiandrosterone-sulphate (DHEA-S; DSL Inc.,
Webster, TX), LH (luteinizing hormone), and FSH (fol-
licle stimulating hormone; Medgenix Diagnostics); the
latter hormone levels were assessed because of their
potential ability to reveal changes in gonadal function
(Deslypere et al., 1987). Dihydrotestosterone was assayed
by an in-house RIA following chromatographic separa-
tion.
Serum-free and bioavailable testosterone (T) and
estradiol were calculated from the total serum hormone
concentrations, serum SHBG, and serum albumin using
a validated equation derived from the mass action law
(Vermeulen, Verdonck & Kaufman, 1999).
RESULTS
Physical and Endocrinological Parameters
Female-to-males were significantly shorter, t (46) =
−4.8, p < .001, and weighed less, t(46) =−2.8, p = .008,
than male-to-females; results that remained unchanged
when correction for age was applied (Table I). Body
mass index (BMI) was comparable (23 kg/m
2
) in both
groups. Alcohol intake was mild and similar in both sexes.
Nearly 50% of male-to-females compared to only 20%
of female-to-males smoked cigarettes, χ
2
(1) = 7.3, p =
.026. In this postoperative setting, 72% of male-to-females
were on estradiol, whereas others were taking conjugated
estrogens (n = 3), estradiol–cyproterone acetate (n = 2),
estrogen–progestagen (n = 1), or no hormonal treatment
(n = 1). One patient suffered a stroke, an absolute con-
traindication for further estrogen treatment. This patient
was not included in further hormonal analysis. Sixty-five
percent of female-to-males were treated by intramuscular
testosterone and 30% by oral testosterone undecanoate.
One female-to-male transsexual was not on androgen
treatment because of recurrent liver function problems.
He was also excluded from further hormonal analysis.
As expected, there was a significant difference in
androgen levels between female-to-males and male-to-
females, Mann–Whitney test U = 0.0, p < .001 (Table II).
Hematocrit, partly reflecting androgen exposure, was
significantly higher in female-to-males, t(46) = 5.9,
p < .001. However, the median testosterone value in
this group was low (285.0 ng/dl), with 25% of pa-
tients reaching the cut-off value for hypogonadism of
320 ng/dl. Usually testosterone treatment should aim
at testosterone concentrations in the mid-normal male
testosterone range. LH and FSH levels were 18.4 and
34.0 mU/ml in male-to-females, and 39.2 and 97.0 mU/ml
in female-to-males, higher than normal values (1–9
and 1–12, respectively). Although all male-to-females
had total testosterone levels within the normal range
for non-transsexual women (10–80 ng/dl) because of
the estrogen effect on sex hormone binding globulin,
only 32.1% reached normal free testosterone levels
(0.2–0.5 ng/dl).
Female-to-male patients rarely reported physical
co-morbidity. One patient was treated for hypertension
and one patient for depression; one patient had Type
1 diabetes and one patient had been diagnosed with
Type 2 diabetes. One patient reported liver problems,
already present before hormonal treatment. Twenty-one
percent of male-to-female patients developed hyperten-
sion (>160/95 mmHg) during sex steroid treatment and
14.3% reported having had a prolactin level above the
upper limit of normal, which was confirmed by review
of medical records. Prolactin levels in all participants
were within the normal limits on blood testing at the
time of research. Twenty-five percent of male-to-female
patients were treated for depression. Hypothyroidism and
hyperlipidemia were mentioned by 7.1% of participants,
whereas one patient had suffered a stroke. No malig-
nancies were reported. No further abnormalities were
observed on the blood examination (data not shown). We
are not aware of any death by suicide in the total group of
transsexuals since the initiation of our gender team.
Partner Relation Parameters
More often transsexuals had a stable sexual rela-
tionship after SRS (52.7%) compared to before (35.3%),
χ
2
(1, n = 51) = 5.06, p = .025 (Table III). This was
particularly the case in male-to-females, χ
2
(1,n = 32) =
4.08, p = .043. The female-to-males had more difficulties
in starting a new relationship after transition. Between the
two groups, there was no difference in having a stable
relationship, χ
2
(1, n = 55) = .37, ns. Nearly one out of
four participants did not have a sexual partner since SRS.
Half of the participants were in a relationship before or
during transition, whereas the others started a new rela-
tionship after surgical reassignment. Before SRS, female-
to-males all had sexual partners of the same biological sex,
where after SRS one female-to-male chose a male partner.
A female partner was chosen by 45.5% of the male-to-
females before SRS,whereas after surgery only 26.3% had
a female partner, χ
2
(1,n = 32) = .40, ns). All partners,
except for one partner of a male-to-female transsexual,
had been informed about the transsexual past. After
SRS, 80% of all participants expressed their satisfaction
with their relational and sexual life. In particular, a
tendency was noted for more female-to-males to report

684 De Cuypere et al.
Table II. Hormonal Parameters
Male-to-female Female-to-male
(n = 28) (n = 19) t or Up
LH (mU/ml) 4.32 <.001
M 18.4 39.2
SD 12.2 20.3
FSH (mU/ml) 5.2 <.001
M 34.0 97.0
SD 27.5 50.3
Prolactin (ng/ml) 199.0 .09
Mdn 4.7 6.6
IQR 3.4–6.9 4.1–9.8
DHEA-S (µg/dl) 116.0 .001
Mdn 105.5 202.0
IQR 74.0–165.8 124.0–320.0
Testosterone (ng/dl) 0.0 <.001
Mdn 18.1 285.0
IQR 12.4–27.8 155.0–823.0
Free T (ng/dl) 0.0 <.001
Mdn 0.12 5.7
IQR 0.1–0.3 3.6–19.4
SHBG (nmol/l) 34.0 <.001
Mdn 98.6 22.1
IQR 53.0–195.3 11.4–34.2
DHT (ng/dl) 20.0 <.001
Mdn 6.8 42.4
IQR 4.5–8.4 23.9–60.6
Estradiol (pg/ml) 180.0 .037
Mdn 13.1 20.4
IQR 9.3–31.0 16.3–32.1
Hematocrit (%) 5.9 <.001
M 40.2 44.9
SD 2.6 2.8
Note. T: testosterone; SHBG: sex hormone binding globulin; DHEA-S:
dehydroepiandrosterone-sulphate; DHT: dihydrotestosterone.
sexual satisfaction in a relation after SRS compared to
before.
Sexual Satisfaction
A total of 5 (9%) out of 55 participants, 3 male-
to-females and 2 female-to-males, reported not having
any sexual activity. For those who had sexual activity,
30 (60%) participants were very satisfied with their sex
life, 18% remained neutral, and 22% were dissatisfied
(single-item measure; Table IV). The participants with a
partner were more satisfied with their sex life than those
who remained single, χ
2
(1,n = 55) = 3.61, p = .058.
A significant correlation between general and sexual
satisfaction was found, r(49) = .49, p < .001. When
evaluating changes in sex life before and after SRS, 75.5%
of participants indicated an improvement and 12.3% a
worsening. Pain, lack of sensation, and difficulties to relax
were reported in this context. A correlation between the
improvement in sex life and the satisfaction with the new
primary sex characteristics (scored with BIS) was found,
r(47) = .29, p = .043. This correlation was not found
when evaluating satisfaction with the secondary or neutral
sexual characteristics. After SRS, the participants were
more often sexually excited than before. This difference
was only statistically significant in the male-to-females,
χ
2
(1, n = 29) = 5.78, p = .016. The more frequently
participants experienced sexual excitement, the more they
felt their sexual life had improved, r(49) = .38, p = .007.
Orgasm
Female-to-male participants masturbated more fre-
quently after SRS compared to before, χ
2
(1,n = 15) =
5.14, p = .023. Before SRS, there was no difference
in frequency of masturbation between the two groups,

Health After Sex Reassignment Surgery 685
Table III. Sexual Relationship Parameters Before and After Sex Reassignment Surgery
Male-to-female Female-to-male
Before After p Before After p
Stable sexual relationship
N 32 32 19 23
% 34.4 59.4 .043 36.8 43.5 ns
No sexual partners since SRS
N 32 23
% 21.9 30.4 ns
Start relationship
N 19 9
% 52.6 47.4 ns 44.4 55.5 ns
Sexual partner (N)1119910
Man (%) 54.5 73.7 0.0 10.0
Woman (%) 45.5 26.3 ns 100.0 90.0 ns
Sexual satisfaction with partner (N)919611
(Very) satisfied (%) 77.7 78.9 50.0 81.9
Neutral–(very) unsatisfied (%) 22.2 21.0 ns 50.0 18.1 ns
Frequency orgasm in sexual intercourse (N)2428 1118
(Almost) always (%) 41.7 50.0 45.5 77.8
Never–sometimes (%) 58.3 50.0 ns 55.5 22.2 ns
Note. p value of difference before and after SRS, McNemar test; for χ
2
test between-group differences
after SRS.
Table IV. Sex Life Before and After SRS
Male-to-female Female-to-male
Before After p Before After p
Sexual satisfaction (N)2921
Satisfied (%) 48.3 76.2
Neutral (%) 27.5 4.8
Unsatisfied (%) 24.2 19.0
Comparison of sex life (N)29 21
Improvement (%) 75.8 75.0
Unchanged (%) 10.3 15.0
Worsening (%) 13.8 10.0
Sexual arousal (N) 2932 1523
(Very) often (%) 17.2 46.9 40.0 60.9
Never–sometimes (%) 82.8 53.1 .016 60.0 39.1 ns
Frequency masturbation (N) 2931 1523
(Very) often (%) 34.5 32.3 20.0 78.3
Never–sometimes (%) 65.5 67.7 ns 80.0 21.7 .023
Orgasm during masturbation (N)23 19
(Almost) always (%) 65.2 94.7
Never–sometimes (%) 33.8 5.3
Change in orgasmic feelings (%) 79.2 73.7
Secretion during excitement (%) 64.3
Secretion during orgasm (%) 76.0
Note. p value of difference before and after SRS, McNemar test; χ
2
test for between-group differences
after SRS.

686 De Cuypere et al.
Table V. Satisfaction with Surgical Results (%)
Male-to-female Female-to-male
Breast augmentation Vaginoplasty Mastectomy Phalloplasty
(n = 21) (n = 29) (n = 14) (n = 19)
Very satisfied 66.6 48.3 35.7 33.3
Satisfied 28.6 37.9 42.8 55.5
Neutral 4.8 10.3 21.4 11.1
Unsatisfied 0.0 0.0 0.0 0.0
Very unsatisfied 0.0 3.4 0.0 0.0
whereas after surgery, the female-to-males masturbated
more, χ
2
(1, n = 54) = 14.19, p = .007, regardless
of having a partner. Seventy-eight percent of the total
group was able to reach an orgasm through masturbation.
No significant difference was found between female-to-
males and male-to-females regarding the ability to reach
orgasm during sexual activity with their partner, χ
2
(1, n
= 46) = 1.07, ns (Table III). In our experience, female-
to-males’ sexual activity preoperatively involved clitoral
stimulation rather than vaginal intercourse, whereas fol-
lowing phalloplasty it referred mostly to intercourse with
their new penis. On the other hand, in male-to-females
preoperative sexual activity occurred through vaginal and
anal penetration, and postoperatively mostly by vaginal
intercourse.
The majority of the male-to-females and the female-
to-males reported changes in their orgasmic feelings.
These feelings changed in both groups: a more powerful
and shorter orgasm for the female-to-males, and a more
intense, smoother and longer orgasm for the male-to-
females. More than two-thirds of the male-to-females
reported the secretion of a fluid in the neovagina, not
only during orgasm but also during sexual excitation.
Expectations
The transsexual persons’ expectations (both in
female-to-males and male-to-females) were met on the
physical, emotional, and social level and less on the
sexual level, with satisfaction rates of 81.5, 94.4, 90.7,
and 66.7%, respectively.
Surgical Parameters
Most participants were very satisfied with the
mammoplasty and vaginoplasty, except for one female
with a shallow vagina, rendering intercourse difficult
(Table V). There was a correlation between satisfaction
with vaginoplasty and sexual life, r(26) = .43, p = .029.
This correlation was not found for breast augmentation
alone. Most female-to-males expressed their satisfaction
with the mastectomy and the phalloplasty. Nobody was
disappointed and two participants remained neutral. One
patient suffered a partial necrosis of the neophallus and
mild urinary incontinence was the problem in another
man. A correlation for the female-to-males between
satisfaction with sex life and satisfaction with the surgical
results was seen, especially regarding the phalloplasty,
r(17) = .68, p = .003.
Table VI shows the comparison on several sexual
items between the female-to-male patients with an erec-
tion prosthesis and those without it. Most participants
without prosthesis were considering having one in the
future. As the number of participants was too small for
further statistical testing, we could only notice the fol-
lowing trend. In female-to-males with prosthesis, sexual
expectations were more realized. They had more sexual
Table VI. Female-to-Males with and Without Erection Prosthesis (%)
With Without
prosthesis, prosthesis,
(n = 12) (n = 10)
(Nearly) totally realization 83.3 60.0
of expectation
More than one partner since SRS 66.7 40.0
Stable sexual relationship 50.0 40.0
(Very) satisfied with sex life 75.0 77.8
Improvement of sex life 83.3 62.5
Sexuality is (very) important 91.7 50.0
(Very) often excited sexually 58.3 60.0
Often preoccupied with provoking 50.0 13.5
sexual fantasies
Often (from several times/week 91.7 80.0
until 1 time/month)
masturbation
(Mostly) always orgasm during 90.9 100.0
masturbation
(Mostly) always orgasm during 60.0 100.0
intercourse
Never pain during intercourse 44.5 100.0

Health After Sex Reassignment Surgery 687
partners and experienced a considerable improvement of
their sex life since SRS. Sexuality was a more important
aspect of life, and they were more often preoccupied with
sex. Nevertheless, both groups expressed the same degree
of sexual satisfaction. Transsexuals with a prosthesis
more often experienced pain during intercourse and
possibly therefore were less able to reach orgasm during
intercourse.
DISCUSSION
The purposes of this study were to describe our
specific hormonal treatment regimen, to explain the
rationale behind it, to evaluate its long-term safety and,
to evaluate sexual health in postoperative transsexual
patients.
Contrary to the usual practice, whereby aninclination
to maximize hormone dosage by patients as well as physi-
cians is seen, our gender team has always treated patients
by a mild dual-model hormonal scheme, aiming at no
or minimal side effects. We believe that pharmacological
ablation of endogenous sex steroid production prior to the
initiation of exogenous cross-sex steroid treatment may
be advisable, in order to reduce dosage of administered
hormones and thus morbidity. One could expect that a
lower dose of cross-sex hormones may then be sufficient
because of increased sensitivity of tissues. Administration
of estrogens alone will suppress gonadotropin output and
by consequence androgen production, but dual therapy
with one compound that suppresses androgen secretion or
action and a second compound that supplies estrogen is
likely to be more effective (T’Sjoen, Rubens, De Sutter,
& Gooren, 2004). Of course, these ideas need systematic
clinical trials in order to find an ideal treatment, where
tailoring for the individual patient will still be necessary.
In this study, it was shown that male-to-females reported
more frequently a decrease in libido. We recommended
they would start hormonal therapy with antiandrogens
to let them adapt to low testosterone levels. This phase
may prove to be an extra diagnostic test. It is remarkable
that in postoperative male-to-females only a minority
reached normal free testosterone levels (reference range
for women). It may be that male-to-females need a small
amount of androgens to be libidinous, as is suggested for
women with hypoactive sexual desire disorder (Laughlin,
Barrett-Connor, Kritz-Silverstein, & von Muhlen, 2000).
Relatively few and minor morbidities were observed
in our patient group that were mostly reversible with
appropriate treatment, possibly in part related to response
bias. A trend toward more general health problems in
male-to-females was seen, which could be explained by
the older age and smoking habits of this group. The
number of complications reported here was markedly
lower than those described by the Amsterdam group, who
reported on a much larger group of transsexual patients
(van Kesteren et al., 1997). Our treatment schedule of
cross-sex hormones is acceptably safe and has some
tentative management and diagnostic implications for
the hormonal treatment of transsexual persons. The low
testosterone values found in female-to-males in our
study can be explained by the fact that blood sampling
was performed regardless of the moment of the last
administration of the hormonal treatment; however, the
high gonadotropin levels that were measured led us to
optimally adjust the testosterone dosage.
In accordance with other studies, our data showed
that male-to-females were significantly older than female-
to-males. The age difference at time of SRS could be re-
lated to the fact that 43.7% of our male-to-female patients
was nonhomosexual compared to 8.6% of our female-to-
males patients. This finding is further supported by the
age difference between homosexual and nonhomosexual
male-to-females at the time of the interview. It is known
from other studies that the nonhomosexual natal male
patients are significantly older at time of evaluation as
well as at time of SRS (Blanchard, Steiner, Clemmensen,
& Dickey, 1989).
Female-to-males had more difficultiesin establishing
a stable relationship after transition. One-third of the
female-to-males did not have any sexual partner after
transition although libido was not impaired. Despite their
masculine presentation and their masculine sex organs,
some avoided a relationship with a potential partner,
because they felt uncertain and anxious about their
maleness. If transsexual patients are able to establish a
stable relationship, they are sexually very satisfied, which
in turn improves their general satisfaction. In contrast with
the data of some researchers (Bodlund & Kullgren, 1996),
who reported that male-to-females have, after transition,
more frequently a new partner whereas the female-to-
males tend to remain with the same partner, we observed
no significant difference between the two groups. It is
remarked that not all transsexual patients wish to inform
their new partners about their natal sex. In a small, dense
country as Belgium it is very difficult to hide one’s
transsexual past. We always give the advice to patients
to inform their partners about their past. Mostly this has a
positive effect on the relationship.
After surgery, more male-to-females acted upon
their attraction to men, as a male sex partner was more
often preferred. Daskalos (1998) suggested that male-
to-females conform before SRS regarding their sexual
orientation and choose a female partner, but we can

688 De Cuypere et al.
assume that some conform after SRS (and then choose
a male partner). From the 19 male-to-females who
had a male partner after SRS, only 14 reported being
exclusively orientated to men. On the other hand, the
male-to-female participants who defined themselves as
homosexual before sex reassignment more often had a
stable relationship after SRS than the nonhomosexual
male-to-females, but this difference was not significant
(70.6% vs. 46.6%). A question to resolve is if the self-
definition of sexual orientation is a reliable measure.
Lawrence, Latty, Chivers, and Bailey (2005) questioned
reported changes in sexual orientation by examining
sexual arousal in male-to-female transsexuals by vaginal
photoplethysmography.
In general, most transsexual individuals indicated
an improvement in their sex life and more sexual ex-
citement after SRS. Most participants were able to reach
orgasmboth throughmasturbation and intercourse.Before
surgery, they experienced their body as strange and not
belonging to themselves. Often they did not accept being
touched by anybody (even by themselves). They were not
preoccupied by sex, but were preoccupied by getting rid
of the unwanted sex organs. After SRS, sexuality can only
improve, on condition they have the right body, with the
right genitals. Our data showed that an improvement of
sex life and sexual satisfaction was correlated with the
satisfaction with the surgical results and the new primary
sex characteristics. A correlation between sexual func-
tioning and the anatomy of the neovagina or neophallus
has been described (Green, 1998). A dysfunctional vagina
is often a reason for sexual dissatisfaction in male-to-
females. The phalloplasty surgery appears to be crucial
in increasing the body image satisfaction. However, if the
surgical results are not optimal, this may actually increase
sexual dissatisfaction.
Although the effect of relief of gender dysphoria after
SRS is the same for both groups, we noticed a difference
regarding some aspects of sexual life. Female-to-males
masturbated more frequently (more than before SRS and
more than male-to-females), and a trend toward increased
arousal and easily reached orgasm (during intercourse as
well as when masturbating) was reported. A study with a
larger number of participants may clarify these trends. A
possible explanation for these group differences may be
that before transition, female-to-males suffer even more
from gender dysphoria, derived from the younger age at
which they seek sex-reassignment. Also, male hormones
influence sexual behavior and libido (Mooradian, Morley,
& Korenman, 1987). The absence of testosterone possibly
explains the effect on the sexual satisfaction rate of
the male-to-females, where one out of four remained
unsatisfied. Male-to-female transsexuals have to deal
with the absence of testosterone, whereas female-to-male
transsexuals have to experience the presence of markedly
higher androgen levels after SRS, compared to the initial
hormonal treatment phase.
A retrospective finding of the current study is
the experience of orgasm changes: a female orgasm
pattern for the male-to-females and a male orgasm
pattern for the female-to-males. This was also reported
earlier by Rehman, Lazer, Benet, Schaefer, & Melman
(1999).
More than two-thirdsof the male-to-females reported
the secretion of a vaginal fluid during sexual excitation
and during orgasm. The hypothesis is that during sexual
excitation this fluid is produced in Cowper’s glands (in
natal males it is called the preejaculatory penile secretion)
whereas during orgasm it originates from the prostate.
Cowper’s glands are situated in the urogenital diaphragm,
beneath the prostate gland, and are not removed during
genital surgery. We expect that the production of this
fluid will decrease in the absence of androgens or by the
administration of estrogens, but further study is necessary.
Details are lacking on the nature of the hormonal control
of these glands. It is clear from studies on castration that
there is a dependence on the testes. Some early studies
have addressed the action of estrogens on the accessory
genital organs in a variety of animals; these reports were
almost exclusively on morphological findings. It was
concluded that a small supply of estrogen appears to
be favorable for the well-being of the male accessory
reproductive organs (Raeside, Christie, & Renaud, 1999).
Informing the postoperative transsexual of the continua-
tion of the fluid production is useful. The spontaneous
lubrification can create more comfort in the sexual
relationship.
Some female-to-male transsexuals did not choose
for an erection prosthesis. They were satisfied with
phalloplasty alone, and did not wish further surgical
interventions. In the group with penile prosthesis, sexual
expectations were more realized, but more often pain
during intercourse was experienced. During phalloplasty,
the free forearm flap is connected with two nerves, one
of two dorsal clitoral nerves for erogenous sensation and
the ileoinguinal nerve for proprioception (the ability to
sense the position, location, orientation, and movement
of a body part). Probably this proprioceptive sensation
during intercourse is responsible for the pain; however, it
has a protective function against perforation of the pros-
thesis (Hoebeke, De Cuypere, Ceulemans, & Monstrey,
2003). Pain may also be explained by an exaggerated
pressure of the erection prosthesis on the free forearm
flap or by irritation of the pubic bone at the place of
fixation.

Health After Sex Reassignment Surgery 689
The response rate remains a difficult problem in this
type of follow-up research. The patients are either difficult
to trace because of the frequent change of residence, or
because of unwillingness to participate in interviews of
this kind. This implies that researchers can never obtain
the profiles of those who fail to respond. This selection
bias cannot be avoided. The longer the postoperative
period, the lower a response rate will be. The response-
rate in the Blanchard et al. (1989) sample was 84.1%
with a mean follow-up interval of 4.4 years. Pf
¨
afflin
and Junge (1990) reported a response rate of 63% after
5.1 years for male-to-female and 6.7 years for female-
to-male transsexuals. Nearly 80% of the population in
Smith’s (2002) study agreed to cooperate with a mean
delay of 22 months. The study of Lawrence (2003)
had a 43% response rate, which was comparable to our
study (51.3%). A possible explanation for the rather
low response rate in the current study could be that all
participants were required to be seen on a face-to-face
basis, involving an outpatient visit. Other limitations of
this research are that data were based on self-reports and
thus are subjective. However, the evaluation of SRS can be
made mainly on the basis of such subjective data, as SRS
is intended to solve a problem that cannot be determined
objectively (Lawrence, 2003).
It is clear that the significance and the importance of
sexuality have undergone an evolution in our study group.
Consequently, we feel that during the preoperative period
more attention should be paid to sexual expectations and
to possible sexual changes, in order to help the patients
cope with these new sensations. Systematic investigation
on a larger number of patients is certainly needed to
gain more insight into sexual functioning of postoperative
transsexuals. A prospective study is needed in male-to-
females to further investigate the relation between libido
and (subnormal) testosterone levels.
ACKNOWLEDGMENTS
The authors are indebted to E. Elaut, I. Bocquaert, A.
Duwel, and E. Feyen for their help and expert assistance
in the completion of this study. G. De Cuypere and
G. T’Sjoen contributed equally to this manuscript.
REFERENCES
Asscheman, H., & Gooren, L. (1992). Hormone treatment in transsexu-
als. Journal of Psychology and Human Sexuality, 5, 39–54.
Asscheman, H., Gooren, L., & Eklund, P. (1989). Mortality and morbid-
ity in transsexual patients with cross-gender hormone treatment.
Metabolism, 38, 869–873.
Blanchard, R., Legault, S., & Lindsay, W. (1987). Vaginoplasty out-
come in male-to-female transsexuals. Journal of Sex and Marital
Therapy, 13, 256–276.
Blanchard, R., Steiner, B., Clemmensen, L., & Dickey, R. (1989).
Prediction of regrets in postoperative transsexuals. Canadian
Journal of Psychiatry, 43, 43–45.
Bodlund, O., & Kullgren, G. (1996). Transsexualism—General outcome
and prognostic factors: A five-year follow-up study of nineteen
transsexuals in the process of changing sex. Archives of Sexual
Behavior, 25, 303–316.
Chivers, M. L., & Bailey, J. M. (2000). Sexual orientation of female-to-
male transsexuals: A comparison of homosexual and nonhomosex-
ual types. Archives of Sexual Behavior, 29, 259–278.
Coleman, E., Bockting, W. O., & Gooren, L. (1993). Homosexual and
bisexual identity in sex-reassigned female-to-male transsexuals.
Archives of Sexual Behavior, 22, 37–50.
Daskalos, C. (1998). Changes in the sexual orientation of six heterosex-
ual male-to-female transsexuals. Archives of Sexual Behavior, 27,
605–614.
De Cuypere, G., Jannes, C., & Rubens, R. (1995). Psychosocial function-
ing of transsexuals in Belgium. Acta Psychiatrica Scandinavica, 91,
180–184.
Deslypere, J. P., Kaufman, J. M., Vermeulen, T., Vogelaers, D.,
Vandalen, J. L., & Vermeulen, A. (1987). Influence of age on
pulsatile luteinizing hormone release and responsiveness of the
gonadotrophs to sex hormone feedback in men. Journal of Clinical
Endocrinology and Metabolism, 64, 68–73.
Doorn, C. D., Poortinga, J., & Verschoor, A. M. (1994). Cross-gender
identity in transvestites and male transsexuals. Archives of Sexual
Behavior, 23, 185–201.
Eicher, W., Schmitt, B., & Berger, C. M. (1991). Transfomationsoper-
ation bei Mann-zu-Frau-Transsexuellen. Darstellung der Methode
und Nachuntersuchung von 50 Operierten. Zeitschrift f
¨
ur Sexual-
forschung, 4, 119–132.
Eldh, J., Berg, A., & Gustafsson, M. (1997). Long term follow-up after
sex reassignment surgery. Scandinavian Journal of Plastic and
Reconstructive Hand Surgery, 31, 39–45.
Green, R. (1998). Sexual functioning in post-operative transsexuals:
Male-to-female and female-to-male. International Journal Impo-
tence Research, 10(Suppl. 1), S22–S24.
Hoebeke, P., De Cuypere, G., Ceulemans, P., & Monstrey, S. (2003). Ob-
taining rigidity in total phalloplasty: Experience with 35 patients.
Journal of Urology, 169, 221–223.
K
¨
ockott, G., & Fahrner, E. M. (1988). Male-to-female and female-to-
male transsexuals: A comparison. Archives of Sexual Behavior, 17,
539–546.
Kuiper, A. J. (1991). Transseksualiteit: Evaluatie van de geslacht-
saanpassende behandeling [Transsexualism: An evaluation of sex
reassignment]. Unpublished doctoral dissertation, Utrecht, The
Netherlands.
Laughlin, G. A., Barrett-Connor, E., Kritz-Silverstein, D., & von
Muhlen, D. (2000). Hysterectomy, oophorectomy, and endogenous
sex hormone levels in older women: The Rancho Bernardo Study.
Journal of Clinical Endocrinology and Metabolism, 85, 645–
651.
Lawrence, A. A. (2003). Factors associated with satisfaction or regret
following male-to-female sex reassignment surgery. Archives of
Sexual Behavior, 32, 299–315.
Lawrence, A. A., Latty, E. M., Chivers, M., & Bailey, J. M. (2005).
Measurement of sexual arousal in postoperative male-to-female
transsexuals using vaginal photoplethysmography. Archives of
Sexual Behavior, 34, 135–145.
Lief, H., & Hubschman, L. (1993). Orgasm in the postoperative
transsexual. Archives of Sexual Behavior, 22, 145–155.
Lindemalm, G., Korlin, D., & Uddenberg, N. (1986). Long-term follow-
up of “sex change” in 13 male-to-female transsexuals. Archives of
Sexual Behavior, 15, 187–210.
Lindgren, T. W., & Pauly, I. B. (1975). A Body Image Scale for evaluating
transsexuals. Archives of Sexual Behavior, 4, 639–656.

690 De Cuypere et al.
Meyer, W., Bockting, W. O., Cohen-Kettenis, P., Coleman, E., DiCeglie,
D., Devor, H., et al. (2001). The Harry Benjamin Gender Dysphoria
Association’s Standards of Care for Gender Identity Disorders,
Sixth Version. Journal of Psychology and Human Sexuality, 13(1),
1–30.
Monstrey, S., Hoebeke, P., Dhont, M., De Cuypere, G., Rubens, R.,
Moerman, M., et al. (2001). Surgical therapy in transsexual patients:
A multi-disciplinary approach. Acta Chirurgica Belgica, 101, 200–
209.
Mooradian, A., Morley, J., & Korenman, S. (1987). Biological actions
of androgens. Endocrine Reviews, 8, 1–28.
Moore, E., Wisniewski, A., & Dobs, A. (2003). Endocrine treatment of
transsexual people: A review of treatment regimens, outcomes, and
adverseeffects.Journal of Clinical Endocrinology and Metabolism,
88, 3467–3473.
Pf
¨
afflin, F., & Junge, A. (1990). Nachuntersuchung von 85 operierten
Transsexuellen. Zeitschrift f
¨
ur Sexualforschung, 3, 331–348.
Pf
¨
afflin, F., & Junge, A. (1998). Sex reassignment. Thirty years of
international follow-up studies after sex reassignment surgery: A
comprehensive review, 1961–1991 (English ed.). Retrieved from
http://www.symposion.com/ijt.pfaefflin/1000.htm
Prior, J., Vigna, Y., & Watson, D. (1989). Spironolactone with physi-
ological female steroids for presurgical therapy of male-to-female
transsexualism. Archives of Sexual Behavior, 18, 49–57.
Raeside, J., Christie, H., & Renaud, R. (1999). Metabolism of oestrone
and oestradiol-17beta to conjugated steroids by the accessory sex
glands of the male pig. Journal of Endocrinology, 163, 49–53.
Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Melman, A.
(1999). The reported sex and surgery satisfactions of 28 postopera-
tive male-to-female transsexuals. Archives of Sexual Behavior, 28,
71–89.
Smith, Y. S. L. (2002). Sex reassignment: Predictors and outcomes
of treatment for transsexuals. Unpublished doctoral dissertation,
University of Utrecht, The Netherlands.
Sorensen, T. (1981a). A follow-up study of operated transsexual males.
Acta Psychiatrica Scandinavica, 63, 486–503.
Sorensen, T. (1981b). A follow-up study of operated transsexual females.
Acta Psychiatrica Scandinavica, 64, 50–64.
Steiner, B. W., & Bernstein, S. M. (1981). Female-to-male transsexuals
and their partners. Canadian Journal of Psychiatry, 26, 178–182.
T’Sjoen, G., Rubens, R., De Sutter, P., & Gooren, L. (2004).
Author’s response: The endocrine care of transsexual people.
Journal of Clinical Endocrinology and Metabolism, 89, 1014–
1015.
van Kesteren, P., Asscheman, H., Megens, J., & Gooren, L. (1997).
Mortality and morbidity in transsexual subjects treated with cross-
sex hormones. Clinical Endocrinology, 47, 337–342.
Vermeulen, A., Verdonck, L., & Kaufman, J. M.(1999). A critical
evaluation of simple methods for the estimation of free testosterone
in serum. Journal of Clinical Endocrinology and Metabolism, 84,
3666–3672.
Verschoor, A. M., & Poortinga, J. (1988). Psychosocial differences
between Dutch male and female transsexuals. Archives of Sexual
Behavior, 17, 173–178.