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Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals

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We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.
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Sex reassignment: outcomes and predictors of
treatment for adolescent and adult transsexuals
YOLANDA L. S. SMITH*, STEPHANIE H. M. VAN GOOZEN, ABRAHAM J. KUIPER
AND PEGGY T. COHEN-KETTENIS
Department of Child and Adolescent Psychiatry, University Medical Centre Utrecht, The Netherlands ;
Department of Medical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
ABSTRACT
Background. We prospectively studied outcomes of sex reassignment, potential differences between
subgroups of transsexuals, and predictors of treatment course and outcome.
Method. Altogether 325 consecutive adolescent and adult applicants for sex reassignment partici-
pated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treat-
ment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were
compared to determine post-operative differences. Adults and adolescents were included to study
predictors of treatment course and outcome. Results were statistically analysed with logistic re-
gression and multiple linear regression analyses.
Results. After treatment the group was no longer gender dysphoric. The vast majority functioned
quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals
expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better
in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment
was largely ba sed upon gender dysphoria, psychological stability, and physical appearance. Male-
to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet
less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual
applicants with much psychopathology and body dissatis faction reported the worst post-operative
outcomes.
Conclusions. The results substantiate previous conclusions that sex reassignment is effective. Still,
clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological
functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk
factors for dropping out and poor post-operative results. If they are considered eligible, they may
require additional therapeutic guidance during or even after treatment.
INTRODUCTION
The phenomenon of transsexualism refers to
individuals who are born with the normal sexual
characteristics of one sex, but have the irrefut-
able conviction of belonging to the other.
Nowadays, many professionals who special-
ize in the treatment of transsexuals regard the
conviction of transsexuals as belonging to some-
one of the other sex as authentic and, conse-
quently, their wish for a sex change to be justified.
The recommended procedure of the Harr y
Benjamin International Gender Dysphoria
Association (Meyer et al. 2001), an inter-
national professional organization regardin g
transsexualism, is to approach the refer ral for
sex reassignmen t (SR) in two phases. In the first
phase, a DSM-IV diagnosis (APA, 1994) is
made. In addition, the eligibility of the patient
to move on to the second phase, the Real-life
* Address for correspondence: Prof. Dr P. T. Cohen-Kettenis,
VU University Medical Centre, Department of Medical Psychology,
P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
(Email: pt.cohen-kettenis@vumc.nl)
Psychological Medicine, 2005, 35, 89–99. f 2004 Cambridge University Press
DOI: 10.1017/S0033291704002776 Printed in the United Kingdom
89
Experience (RLE), is assessed. In this phase the
applicant’s ab ility to live in the desired role and
its consequences, and the strength of the desire
for SR are evaluated. If the social role change
during the RLE , which is usually supported by
hormonal therapy, results in a satisfactory out-
come, the applicant will be referred for surgery
(see Table 1).
Although SR is presently regarded as effective
in treating transsexualism, the most extreme end
of Gender Identity Disorder (GID) (Pfa
¨
fflin &
Junge, 1992, 1998; Eldh et al. 1997; Cohen-
Kettenis & Gooren, 1999 ; Rehman et al. 1999;
Meyer et al. 2001 ; Smith et al. 2001, 2002 ; Day,
2002; Lawrence, 2003), prospective studies are
needed to enhance knowledge about the benefits
and limitations of SR. In spite of strict prior
selection and counselling during treatment, an
estimated 1–2% of those treated express regrets
about SR (Pfa
¨
fflin, 1992; Pfa
¨
fflin & Junge,
1992, 1998 ; Kuiper & Cohen-Kettenis, 1998).
Considering the invasi ve and irreversible treat-
ment of SR, it is imperative to try and prevent
post-operative regret. This requires the identi -
fication of predictors of regret or poor post-
operative functioning. In some follow-up
studies different factors are proposed as influ-
encing the outcomes of SR negatively (e.g.
Wa
˚
linder et al. 1978; Spengler, 1980; Lothstein,
1982; Lundstro
¨
m et al. 1984; Blanchard, 1985;
Lindemalm et al. 1987; Blanchard et al. 1989;
Ross & Need, 1989; Pfa
¨
fflin, 1992 ; Pfa
¨
fflin &
Junge, 1992; Kuiper & Cohen-Kettenis, 1998 ;
Lande
´
n et al. 1998). These factors lie in the area
of psychological functioning, sexual orientation,
age at assessment, onset age of gender dys-
phoria, family history and support, professional
support during SR, and surgical outcomes.
However, the quality of the few existing follow-
up studies is rather poor given their mostly
retrospective nature. Sound prospective studies
are needed to identify predictors of post-
operative functioning more consistently and
reliably.
In the present large-scale prospective foll ow-
up study, we investigated two separate though
related topics : the outcomes of SR and the pre-
diction of favourable or poor outcomes. There-
fore, we first evaluated whether transsexuals
actually improve in important areas after SR,
and confirm some of the beneficial effects of SR
previously establ ished in the mostly retrospec-
tive follow-up studies (e.g. Mate-Kole et al.
1990; Day, 2002; Lawrence, 2003). Secondly,
we studied differences between sexes [male-to-
females (MFs) an d female-to-males (FMs)] and
subtypes (homosexuals and non-homosexuals)
in various areas of functioning (e.g. gender
dysphoria, body dissatisfaction, physical ap-
pearance, psychological functioning) after SR.
To our knowledge, subtype differences have not
yet been prospectively studied. These research
questions were, however, only studied in adult
transsexuals, because the adolescent results
have been published previously (Smith et al.
2001, 2002). Post-operatively, feelings of regret,
evaluation of treatment, satisfaction with surgi-
cal results, social and sexual functioning were
evaluated.
The other topic concerned predictors of the
course and outcomes of SR. We exami ned
which factors clinicians ba sed their referral on
for SR. The factors were age, sex, sexual orien-
tation, onset age of gender dysphoria, gender
dysphoria in childhood and at application,
social support, body dissatisfaction, physical ap-
pearance and psychological functioning. Finally,
we examined which factors predicted treatment
course (i.e. dropping out), post-operative func-
tioning, and treatment satisfaction.
Table 1. Progres sion in the SR procedure and matching sample sizes used in analyses
SR
procedure
Diagnostic
1st phase
a
(Applicants)
Not referred
for 2nd phase
b
(Non-starters)
Referred for,
started, continued
2nd phase
b
(Starters)
Referred for,
started, dropped out
2nd phase
b
(Drop-outs)
Referred for,
completed
SR surgery
(Completers)
1–4 years after
SR surgery
(Follow-up)
MFs 220 74 146 29 117 94
FMs 105 29 76 5 71 64
Included 325 103 222 34 188 158
a
In the first phase a DSM diagnosis is made and eligibility is assessed for starting hormone treatment and the Real-life Experience.
b
In the second phase hormone treatment and the Real-life Experience is started.
90 Y. Smith et al.
METHOD
Subjects
A total of 325 consecutive adolescents and
adults, who applied for SR at VU University
Medical Centre in Amsterdam (VUmc) or Uni-
versity Medical Centre Utrecht (UMCU), par-
ticipated. Of these, 222 (146 MFs, 76 FMs)
started hormone treatmen t : the starter group.
Twenty-nine MFs and 5 FMs stopped hormone
treatment: the drop-out group. The group
who completed SR consisted of 188 patients
(117 MFs, 71 FMs) : the completer group. The
group who never started hormone treatment
consisted of 103 patients (74 MFs, 29 FMs).
Pre-test data from this no-starter group varied
from 89 to 103. At follow-up, some participants
had moved abroad, while others were untrace-
able, which resulted in 158 (94 MFs, 64 FMs)
participants who were interviewed. Follow-up
data ranged between 136 and 158 because not all
participants were willing or able to take part in
both an interview and a questionnaire session
(Table 1).
To examine the outcome issue we used data
of 162 ad ults. Pre-test data were obtained from
all ad ults (104 MFs, 58 FMs; 94 homosexuals,
68 non-homosexuals). Follow-up interview data
were gathered from 126 adults (i.e. 78 %;
77 MFs, 49 FMs; 71 homosexuals, 55 non-
homosexuals). Questionnaire data for different
measures fluctuated from 101 to 126. Since
SR patients do not undergo all possible oper-
ations, data on breast augmentation were
gathered from 52 MFs (21 homosexuals, 31
non-homosexuals), and on meta idoioplasty or
phalloplasty from 10 FMs (4 homosexuals, 6
non-homosexuals). Scores on the Appraisal of
Appearance Inventory were obtained from 57
adults.
Instruments
Biographical data
The Biographical Questionnaire for Trans-
sexuals, a semi-structured interview, contains
211 items on variables, such as cross-gender
feelings and behaviour, social and sexual con-
tacts (Verschoor & Poortinga, 1988; Doorn et al.
1994). The following items were used : sex (MF
or FM), onset age of cross-gender feelings,
childhood GID symptoms (11 items, see below),
age at application, and sexual orientation.
Concerning this last item, participants who
exclusively reported a homosexual preference
(MFs sexually attra cted to biological males ;
FMs to biological fema les) were included in
the homosexual group. Participants with an
asexual, heteros exual, and/or bisexual pref-
erence were included in the non-homosexual
group. Age at the start of hormone therapy and
surgery were obtained from medical files.
The GID in Childhood Scale was constructed
from the Biographical Questionnaire for
Transsexuals (Verschoor & Poortinga, 1988 ;
Doorn et al. 1994) to measure the self-reported
presence of GID symptoms in childhood. There
are 11 items (Cronbach’s a=0
.
81) concerning
the strong wish to be of the opposite sex in early
childhood, cross-gender appearance of the child,
cross-dressing, play and peer preference, and
cross-gender behaviour. Because of differences
in the numbers and types (i.e. quantitative
versus qualitative) of response categories, ans-
wers were dichotomized, resulting in a total score
ranging between 0 and 11, with the higher scores
indicating more childhood GID symptoms.
The Social Support Scale. This scale has 10
items enquiring about the patient’s eight closest
acquaintances (Van Tilburg, 1988). Scalability
coefficient H, calculated by means of a Mokken
analysis (Molenaar, 1982) and calculated for all
relationships together, was 0
.
38. Sumscores
range from 0 to 160, with the higher scores in-
dicating more support.
Gender dysphoria. This was measured with the
Utrecht Gender Dysphoria Scale, containing
12 items on which the subject rated agreement
on a 5-point scale. Scores range from 12 to 60.
Higher scores indicate more gender dysphoria
(Cohen-Kettenis & van Goozen, 1997).
Body dissatisfaction. A Body Image Scale
(Lindgren & Pauly, 1975), adapted for a Dutch
sample (Kuiper, 1991), was used. There are 30
items divided into three subscales: primary and
secondary sex characteristics, and neutral body
parts, with higher scores representing more dis-
satisfaction.
Physical appearance. On the Appraisal of Ap-
pearance Inventory three independent observers
Outcomes and predictors of sex reassignment 91
(the diagnostician, a nurse, the researcher) rated
the subject’s appearance on 14 five-point scales
of gender compatibility. The characteristics
were: hair, facial hair, larynx, voice, figure,
height, skin, hands/feet, muscularity, chin, nos e,
jaw, speech, and gestures/movement. Lower
scores reflect a better appearance in match-
ing the new gender. Intra-class correlation
coefficients between observers for each of the
14 items ranged from 0
.
68 to 0
.
79.
Psychological functioning. The Dutch Short
MMPI (Luteyn et al. 1980) contains 83 items
measuring Negativism, Somatization, Shyness,
Psychopathology, and Extroversion. Higher
scores indicate more dysfunction on the first
four scales but less on Extroversion.
The Dutch version of the Symptom Check
List (Derogati s et al. 1973 ; Arrindell & Ettema,
1986) has 90 items enquiring about recent
complaints. Subscales are: Agoraphobia,
Anxiety, Depression, Somatization, Obsession/
Compulsion, Suspicion, Hostility, and Sleeping
problems. The total score for Psychoneuroticism
ranges from 90 to 450. Higher scores indicate
more psychological instability.
Treatment evaluation and post-treatment func-
tioning. To evaluate post-operative functioning
13 items measured post-operative functioning
and (dis)satisfaction (e.g. with questions about
treatment, regret, social and sexual functioning,
and social experiences) (Doorn et al. 1996).
Patients also completed a questionnaire about
the functioning of vagina/penis and breasts (aug-
mentation or removal), and surgical satisfaction
(Cohen-Kettenis & van Goozen, 1997).
Post-operative Functioning Scale. Twenty-one
items (Cronbach’s a=0
.
87) measured post-
operative functioning and satisfaction with SR
(Doorn et al. 1996) and resulted in a single score
with higher scores reflecting worse functioning
and more dissatisfaction. (See Jo urnal’s website
for Appendix with specific items.)
Procedure
The GID in Childhood Scale and the Social
Support Scale were used at pre-test. Gender
dysphoria, body dissatisfaction, physical ap-
pearance and psychological functioning were
assessed before and after SR to measure change.
The remaining instruments were administered at
follow-up.
Except for the GID in Childhood Scale, the
Social Support Scale, and the Post-operative
Functioning Scale, all instruments were used to
examine the issue of outcome. All instruments
administered at pre-test were used to investigate
predictors of eligibility for and drop-outs of SR.
Follow-up data of the completer group were
used to develop the Post-operative Funct ioning
Scale, investigating predictors of outcomes
of SR.
Pre-test data were gathered during the first
diagnostic procedure after the first interview.
Follow-up data were gathered at least 1 year
after surgery. Sessions took between 2 and
3 hours. The Ethics Committees of the UMCU
and VUmc approved the study.
Statistical analyses
Changes over time in treated adults were
analysed with univariate paired-sample t tests,
applying the Bonferroni correction [dividing
the number of tests (19) by 5%] and using a
significance level of 0
.
003 for these results
(Table 2). Post-operative Sex (MF v. FM) and
Subtype (homosexual v. non-homosexual) dif-
ferences were studied with univariate or multi-
variate analyses of variance [(M)ANOV As]
(Table 3). Nominal or ordinal data were ana-
lysed per item with the x
2
test or Mann–Whitney
U test respectively.
To identify which factors predicted eligibility
for hormone treatment and premature drop-
out, logistic regression analyses were performed
with group membership as the criterion variable
(no-starter and starter, completer and drop-out
respectively). Since we had no a priori hypoth-
eses about group prediction, the first (stepwise)
analysis included all 17 factors : age, sex, sexual
orientation, onset age of gender dysphoria, GID
symptoms in childhood, gender dysphoria at
assessment, social support, body dissatisfaction
(3 scales), physical appearance, and psycho-
logical functioning (2 tests: 1 and 5 scales).
Next, we conducted a (simultaneous) logistic
regression analysis using the significant pre-
dictors. In case of unequal sample sizes cut
values were reset to achieve the highest sensi-
tivity and specificity.
92 Y. Smith et al.
Predictors of post-operative functioning were
identified with a multiple linear regression analy-
sis with the Post-operative Functioning Scale as
the dependent variable. Seven of the 17 factors
were relatively independent and included as
predictors in the first (stepwise) analysis: sex,
sexual orientation, physical appearance, sec-
ondary sex characteristic s, extroversion, psycho-
pathology, and psychoneuroticism. Patients
with missing values were deleted listwise. Sig-
nificant predictors were analysed in a second
(simultaneous) multiple linear regression.
RESULTS
Outcomes of the adult transsexuals
Biographical data
The mean age of the transsexuals who com-
pleted SR was 30
.
9 years (range 17
.
7–68
.
1 years)
at application and 35
.
2 years (range 21
.
3–71
.
9
years) at follow-up. Cross-sex hormone treat-
ment started at the mean age of 31
.
6 years
(range 17
.
9–68
.
3 years). The average duration
between starting hormone treat ment and surgery
was 20
.
4 months (range 12–73 months). The
Table 2. Pre-t est and post-test scores of the adult follow-up sample
Pre-test Post-test
Paired Two-tailed
Mean
S.D. Mean S.D. tp
Gender dysphoria 54
.
37
.
114
.
83
.
049
.
5 <0
.
001
Physical appearance 44
.
79
.
633
.
810
.
210
.
9 <0
.
001
Body dissatisfaction
Primary sex characteristics 18
.
12
.
76
.
63
.
225
.
5 <0
.
001
Secondary sex characteristics 34
.
86
.
925
.
26
.
813
.
7 <0
.
001
Neutral body characteristics 46
.
89
.
636
.
58
.
011
.
3 <0
.
001
Psychological functioning
Negativism 22
.
67
.
717
.
17
.
86
.
8 <0
.
001
Somatization 9
.
17
.
66
.
65
.
33
.
10
.
003
Shyness 14
.
79
.
310
.
07
.
35
.
8 <0
.
001
Psychopathology 3
.
23
.
02
.
42
.
62
.
80
.
006
Extraversion 13
.
86
.
515
.
55
.
62
.
90
.
005
Psychoneuroticism 143
.
040
.
7 120
.
331
.
45
.
5 <0
.
001
Anxiety 15
.
25
.
313
.
04
.
54
.
0 <0
.
001
Agoraphobia 9
.
43
.
68
.
63
.
22
.
10
.
040
Depression 29
.
311
.
322
.
58
.
45
.
3 <0
.
001
Somatization 18
.
27
.
016
.
74
.
42
.
30
.
024
Inadequacy 15
.
85
.
813
.
54
.
54
.
1 <0
.
001
Sensitivity 28
.
29
.
124
.
46
.
54
.
4 <0
.
001
Hostility 7
.
82
.
47
.
42
.
11
.
50
.
147
Sleeping problems 5
.
42
.
94
.
62
.
22
.
30
.
024
Table 3. Differences between the adult sexes and subtypes at follow-up
MFs
[mean (
S.D.)]
FMs
[mean (S.D.)]
HOs
[mean (S.D.)]
NHs
[mean (S.D.)]
Sex
F(p)
Subtype
F(p)
Age 38
.
6 (12
.
3) 29
.
6(8
.
3) 31
.
7 (10
.
7) 39
.
6 (11
.
7) 16
.
0(<0
.
001) 6
.
4(0
.
01)
Gender dysphor ia 15
.
4(3
.
1) 13
.
9(2
.
8) 6
.
6(0
.
01) 1
.
3(0
.
27)
Physical appearance 38
.
2(9
.
3) 26
.
0(6
.
9) 28
.
3(<0
.
001) 2
.
0(0
.
16)
Body dissatisfaction 3
.
1(0
.
03) 1
.
2(0
.
33)
Primary sex characteristics 6
.
0(2
.
2) 7
.
6(4
.
2) 7
.
0(0
.
01)
Dutch Short MMPI 2
.
1(0
.
07) 2
.
2(0
.
06)
Somatization 5
.
6(4
.
8) 7
.
9(5
.
5) 4
.
0(0
.
047)
Extraversion 13
.
8(5
.
4) 18
.
0(5
.
0) 17
.
1(5
.
3) 13
.
6(5
.
4) 9
.
2(0
.
003) 6
.
9(0
.
01)
Symptom Check List 2
.
4(0
.
02) 2
.
6(0
.
009)
Depression 24
.
6(9
.
8) 19
.
7(4
.
7) 6
.
5(0
.
01)
Somatization 15
.
2(3
.
7) 18
.
2(4
.
7) 11
.
0(0
.
001)
Sleeping problems 4
.
3(2
.
0) 5
.
0(2
.
3) 5
.
2(0
.
02)
MFs, male-to-female transsexuals; FMs, female-to-male transsexuals; HOs, homosexual transsexuals; HNs, non-homosexual transsexuals.
Outcomes and predictors of sex reassignment 93
average duration between surgery and follow-up
was 21
.
3 months (range 12–47 months).
At follow-up, main effects for Sex and Sub-
type were found for age. FMs and homosexuals
were younger than MFs and non-homosexuals
respectively (Table 3).
At follow-up 5 subjects (4
.
9%) were student s,
38 (36
.
9%) had jobs, 3 (1
.
9%) had retired, and
58 (56
.
3%) were unemployed. The majority
(n=59) lived independently (56
.
2%), 27 sub-
jects (25
.
7%) each lived together with another
adult with or without children, 9 (8
.
6%) were
living with (one of) their parents, 2 (1
.
9%) were
head of an incomplete family, and the remaining
8(7
.
6%) lived in a guest house or boarding
house.
Gender dysphoria. At follow-up there was less
gender dysphoria; the low post-test scores rep-
resent a virtual absence of gender dysphoria
after SR (Table 2). A main effect of Sex was
found with FMs feeling less gender dysphoric.
No Subtype difference in post-operative gender
dysphoria was found (Table 3).
Body dissatisfaction. The majority (n=98,
91
.
6%) were (very) satisfied with their overall
appearance; 9 (8
.
4%) were neutral ; no one was
dissatisfied. Satisfaction with primary sex, sec-
ondary sex, and neutral characteristics had
increased after SR (Table 2). A MANOVA
showed that FMs were more dissatisfied with
their primary sex characteristics at post-test
than MFs. No Subtype differences were found
(Table 3).
Physical appearance. The group scored lower
on the Appraisal of Appearance Inventory at
post-test (Table 2), indicating that their ap-
pearance better matched the new gender. The
physical appearance of FMs was more compat-
ible than that of the MFs, but there was no
Subtype difference (Table 3).
Psychological functioning. At follow-up the
group functioned psycho logically better. Scores
on Negativism and Shyness had improved.
Scores on Somatization, Psychopathology, and
Extroversion showed a tendency towards im-
provement (pf0
.
006). In general, follow-up
scores indicated fewer psychological problems
(Table 2). Comparing pre- and post-test g roup
means with Dutch normative data, most scores
remained within the average range at follow-up,
although Extroversion scores were below aver-
age. Somatization scores were high at pre-test.
The mean Psych oneuroticism score was lower
after SR [see Table 2 for lower scores on four of
the eight subscales (p<0
.
001)]. These scores can
only be compared with Dutch normat ive data
for males and females separately. Both the MF
(p=0
.
001) and FM (p<0
.
001) group showed
improvement in mean scores. The MFs went
from above average at pre-test (mean=143,
S.D.=38
.
0) to average at post-test (mean=123,
S.D.=36
.
0); the FMs went from high (mean=
143,
S.D.=44
.
8) to above average at follow-up
(mean=116,
S.D.=22
.
8).
The Dutch Short MMPI showed a marginally
significant Sex effect, with FMs being more
extrovert. The Sex effect on the Symptom Check
List showed MFs as being more depressed than
FMs (Table 3). There was also a marginally
significant Subt ype effect on the Dutch Short
MMPI, with homosexuals scoring more favour-
ably on Somatization and Extroversion. The
Symptom Check List showed a Subtype effect
with homosexuals scoring lower on Sleeping
Problems and Somatization (Table 3).
Thus, although the groupas a whol e functioned
psychologically rather well at application, their
psychological stability had improved after SR.
In addition, and post-operatively, FMs and
homosexuals functioned psychologically better
than MFs and non-homosexuals respectively.
Treatment evaluation and post-treatment func-
tioning. The vast majority (98
.
4%) expressed
no regrets about SR. One non- homosexual
MF had experienced such strong regrets
during and after treatment that she would not
elect for SR again, if given a second oppor-
tunity. In contrast, a second non-homosexual
MF, who expressed some regrets, reported she
would choose SR again. Five non-homosexuals
(4 MFs, 1 FM) reported some regrets during
treatment only, but expressed no desire or in-
tention to resume their original gender role. No
differences were found between the sexes in re-
ported regret during (Z=x1
.
4, p=0
.
2) or after
SR (Z=x1
.
1, p=0
.
3). During treatment more
non-homosexuals reported feelings of regret
(Z=x3
.
1, p=0
.
002).
94 Y. Smith et al.
Social life and social contacts. The majority
(n=90, 89
.
1%) felt accepted by most people, 8
(7
.
9%) by some, 3 (3%) by no one. Altogether
84 individuals (83
.
2%) felt supported in their
new gender role by (almost) everyone they
knew, whereas 11 (10
.
9%) felt supported by
some people. Despite the fact that 6 subjects
(5
.
9%) did not feel supported, they were able
to rely on some individuals during difficult
times. Four subjects (3
.
9%) had no one to
turn to when times got hard. Still, the vast
majority (99, 96
.
1%) could rely on at least
some others during difficult times. In total,
18 individuals (17
.
3%) sometimes felt they
were being laughed at, 2 (1
.
9%) had experi-
enced being ridiculed by strangers; 84 (80
.
8%)
had never experienced any such adverse reac-
tions. Over 98% (n=102) felt they were com-
pletely taken seriously by most people. Two
(1
.
9%) only felt taken seriously by a few close
friends. No one reported not being taken
seriously by anyo ne.
MFs and FMs felt equally accepted
(Z=x 0
.
8, p=0
.
4). However, FMs had more
support in the new gender role (Z=x 2
.
5,
p=0
.
01) and were more able to rely on signifi-
cant others during difficult times (Z=x 2
.
2,
p=0
.
03). Although MFs were more often
laughed at or ridiculed (Z=x 3
.
5, p<0
.
001),
they reported feeling taken equally seriously by
(almost) all people (Z=x 1
.
7, p=0
.
08). Homo-
sexuals felt more supported (Z=x 2
.
0, p=0
.
04)
and taken more seriously than non-homo-
sexuals (Z=x 2
.
5, p=0
.
01).
Relationships and sexuality. The majority (n=
46, 88
.
5%) of the 50 subjects who had a steady
sexual partner were satisfied with their sex life, 3
(5
.
8%) expressed a neutral view, and 3 (5
.
8%)
were dissa tisfied. Of the 84 subjects (82
.
4% of
the follow-up sample) who were sexually active,
the majority (53, 63
.
1%) achieved orgasm al-
ways or regularly, 16 (19%) sometimes, and 15
(17
.
9%) never.
A larger percentage (x
2
=4
.
2, p=0
.
04) re-
ported a homosexual (94, 58
.
0%) than a non-
homosexual orientation (68, 42
.
0%). Within the
FMs a greater proportion (x
2
=5
.
9, p=0
.
015)
had a homosexual orientation (70
.
7%) than the
MFs (51
.
0%). More of the sexually active FMs
(81
.
6%) than of the MFs (42
.
1%) achieved
orgasm always or regularly (Z=x 2
.
4, p=0
.
01).
Yet, both sexes reported equal satisfaction with
their sex life (Z=x0
.
6, p=0
.
5). No Subtype
differences were found.
Satisfaction with surgery. For FMs breast
removal is emotionally the most important sur-
gery. They are advised to postpone metaidoio-
plasty (transformation of the hypertrophic
clitoris into a micropenis) or phalloplasty in
view of the fact that surgical techniques are
steadily improving. Eleven FMs (28
.
9%) were
satisfied with their breast removal, 5 (13
.
2%)
were dissatisfied due to the visibility of the scars,
and 22 (57
.
9%) were not completely satisfied.
Four FMs were satisfied with their metaidoio-
plasty or phalloplasty. One FM was dissatisfied
because of urinary problems, while four were
not completely satisfied.
For the MFs vaginoplasty is the most im-
portant surgical intervention. The majority of
MFs (47, 70
.
1%) were satisfied; 15 (22
.
4%)
were not completely satisfied, mostly because
they considered their vagina not deep or femi-
nine enough. Five MFs (7
.
5%) were dissatisfied,
because they were unable to achieve sexual
arousal or orgasm, or because corrective surgery
was needed. The majority (34, 65
.
4%) were
satisfied with their breast augment ation ; 15
(28
.
8%) were not co mpletely satisfied, and three
felt uneasy about their breasts being too far
apart.
Predictors of the course and outcomes of
adolescent and adult transsexuals
Prediction of elig ibility criteria
Eligibility for SR was largely based upon the
factors gender dysphoria, psychoneuroticism,
and physical appearance. For the precise weight
of each predictor variable and the constant in
this equation model, see Table 4. Stronger
gender dysphoria (higher scores), more psycho-
logical stability (lower scores on Psycho-
neuroticism), and a feminine look for MFs and
a masculine look for FMs (lower scores on
physical appearance), increased the probability
of the clinician referring the applicant to start
hormone treatment. With these three predic-
tor variables 78% of the applicants were cor-
rectly assigned to the no-starter (52%) or the
starter (88 %) group (cut value=0
.
63).
Outcomes and predictors of sex reassignment 95
Prediction of the course of treatment
The probability that a transsexual discontinued
hormone treatment depended on sex, psycho-
pathology, childhood GID symptoms, and gen -
der dysphoria (Table 4). A negative coefficient
means that a factor contributes negatively to the
probability of being a drop-out. The relatively
high beta value of the factor sex reflects being a
FM. Thus, the combinat ion of being a MF with
more psychopathology and childhood GID
symptoms, yet less gender dysphoria at assess-
ment, increased the likelihood of premature
drop-out. Together these four predictors cor-
rectly assigned 68% of the transsexuals to the
completer (68%) or the dr op-out (69 %)
group (cut value=0
.
15).
Prediction of post-operative functioni ng
The level of post-operative functioning could be
predicted by the patient’s sexual orientation,
psychological stability, and dissatisfaction with
secondary sex characteristic s at assessment. The
beta weights (see Beta column in Table 5) show
the relative importance of the variables con-
tributing to the predictability of the quality of
post-operative functioning (R
2
=0
.
17). As high-
er scores on the Post-operative Functioning
Scale reflect more dysfunction and dissatis-
faction, the predicted score of an applicant on
this scale increased with a non-homosexual
orientation, more psychopatholog y and dissat-
isfaction with secondary sex characteristics at
assessment.
DISCUSSION
One aim of this prospective study was to inves-
tigate which areas of functioning improve as a
consequence of SR. The main symptom for
which the patients had requested treatment,
gender dysphoria, had decreased to such a de-
gree that it had disappeared. Satisfaction of the
patients with their sex characteristics had im-
proved to the point of content, confirming pre-
vious results (Green & Fleming, 1990 ; Pfa
¨
fflin &
Junge, 1998), and according to observers, their
appearance better matched the new gender.
Psychological functioning had also improved
(see Mate-Kole et al. 1990). Thus, it seems safe
to conclude that the transsexuals had improved
in important areas of functioning and that 1–4
years after surgery, SR appeared therapeutic
and beneficial. Furthermore, the vast majority
expressed no regrets about their SR.
Post-operative evaluation showed that the
majority functioned quite well socially. A small
minority, however, lacked support and accept-
ance, and were ridicu led. Surprisingly, 98 % felt
taken seriously. This somewhat rose-coloured
view may be explained by the fact that the social
support received and the relief about the new
situation may have put adverse reactions into
perspective, whereas disappointing experiences
may have been played down to reduce co gnitive
dissonance after undergoing such invasive and
irreversible interventions.
At follow-up, the majority were content with
their sex life, and those who were sexually
active, reported achieving orgasm. This has
been reported previously (e.g. Rakic et al. 1996;
Rehman et al. 1999), but in MFs the capacity
Table 4. B coefficients and constants of the
factors predicting group membership
Predictor variables
Starter group Drop-out group
Bpvalue Bpvalue
Sex x1
.
82 0
.
006
Sexual orientation
Onset age of gender dysphoria
Age at application
GID symptoms in childhood 0
.
18 0
.
026
Gender d ysphoria 0
.
08 <0
.
001 x0
.
05 0
.
030
Social support
Primary sex characteristics
Secondary sex characteristics
Neutral sex characteristics
Physical appearance x0
.
05 0
.
003
Psychoneuroticism x0
.
01 <0
.
001
Negativism
Somatization
Shyness
Psychopathology 0
.
12 0
.
024
Extroversion
Constant 1
.
00 0
.
442 x0
.
04 0
.
972
Table 5. Factors predicting post-operative
functioning
Model B Beta p value
Sexual orientation x3
.
70 x0
.
24 0
.
002
Psychopathology 0
.
43 0
.
17 0
.
028
Dissatisfaction secondary
sex characteristics
0
.
31 0
.
28 <0
.
001
Constant 16
.
80 <0
.
001
96 Y. Smith et al.
for orgasm has been reported to decrease post-
surgically (Lief & Hubschman, 1993).
The findings supp ort the conclusion that after
SR most transsexuals functioned socially and
sexually well. One MF expressed deep regrets.
She indicated that professional guidance re-
garding adverse consequences (i.e. intolerance
of society, family and her own children), would
have made the transition more endurable. This
stresses the need for good aftercare.
Comparing the sexes, the FMs showed better
results, supporting the results of earlier studies
(see Introduction). This might be due to their
more convinci ng gender role behaviour and
looks and their type of transsexualism, imply-
ing an earlier age at application. More FMs
than MFs were capable of achieving orgasm.
This can be attributed to hormonal effects (van
Goozen et al. 1995) or to the fact that most FMs
lived with their enlarged clitoris. Then again, it
may also portray different meanings of sexuality
in males and females, since both sexes reported
equal satisfaction with their sex life. Contrasting
most of the more favourable FM findings are
the greater reported satisfaction of the MFs
with surgical results. This is unde rstandable
given that most FMs did not (yet) have a penis.
For the FMs the ability to live in the new gender
and sexual role clearly awaits the advancement
of surgical techniques.
With respect to subtype differences, homo-
sexuals were younger and functioned psycho-
logically better than non-homosexuals. No dif-
ferences were found in gender dysphoria, body
dissatisfaction, or physical appearance. Only
non-homosexuals reported some regrets during
treatment, and two during and after SR, which
they all related to a lack of acceptance and
support from others. The better functioning
of homosexual s may also be explained by their
sexual orientation. Subtype differences could
reflect different aetiological backgrounds. Be-
cause the onset age and age at application have
been found to be earlier in homosexuals, it is
likely that non-homosexuals encounter more
problems in life before applying for SR. Also,
post-surgically, homosexuals will have op-
posite gender partners, thus forming hetero-
sexual couples. This still is socially more
acceptable.
The less favourable outcomes of the non-
homosexuals carry significant implications for
clinical practice. If considered eligible for SR,
non-homosexuals should be able to receive
additional guidance in coping with adverse
consequences, such as a more troubled psycho-
logical functioning, or a more critical environ-
ment.
In conclusion, our data substantiate findings
from mostly retrospective follow-up studies that
SR is effective. Some individuals probably need
a more thorough diagnostic procedure and
more therapeutic support, sometimes even after
treatment, than is currently the case. For most
transsexuals in this study, the strict eligibility
criteria and profes sional guidance as currently
provided appears to be sufficient, as reflected by
the overall favourable outcomes of SR. How-
ever, alleviation of the gender problem is not
equivalent with an easy life. Apparently, clin-
icians need to be alert for signs that a trans -
sexual applicant will not be able to cope with
adversities during treatment.
Another goal was to identify predictors of
the course and outcomes of SR. We found that
clinicians assessed applicants to be eligible for
hormone treatment when they were more gen-
der dysphoric, psychologically more stable, and
when the physical appearance better matched
the new gender role. Given the nature of the
problem, it is not surprising that strong gender
dysphoria was one of the main predictors. Since
an unfavourable physical appearance could be a
risk factor for post-operative regret (Wa
˚
linder
et al. 1978), it is interesting to observe that the
clinicians also took this factor into account
when deciding upon referral. Furthermore,
clinicians greatly valued the applicant’s psycho-
logical functioning (see also Kuiper & Cohen-
Kettenis, 1998). These factors predicted 88 % of
the starter group. Clearly, clinicians must have
had other reasons for referring the remaining
12%, the most likely factor being the diagnosis.
They might also have appraised certain risk
factors as relatively harmless in view of existing
protective factors (e.g. strong social support,
adequate coping skills).
We found transsexuals to be more at risk
for dropping out of treatment when they were
MFs, showed more psychopathology, more
GID symptoms in childhood, yet less gender
dysphoria at application. The greater vulner-
ability of MFs to drop out is understandable
given that FMs fare better post-operatively.
Outcomes and predictors of sex reassignment 97
Unfortunately, our data do not permit us to
distinguish during treatment between the impac t
of psychopathology , on the one hand, and of
interactive effects of psychopathology with ex-
ternal forces, on the other. We cannot rule out
the possibility that it is not psychopathology
per se that increases the probability to drop out,
but rather a combination of psychological vul-
nerability and personal circum stances, such as
abandonment by a partner. One should also
bear in mind that the drop-outs stopped hor-
mone treatment during our data collection; it
is possible, however, that they will reapply later
in life.
Our finding of an association between more
childhood GID symptoms an d greater drop
out seems puzzling. It is in contrast with the
literature on SR risk factors and clinically
counter-intuitive. Early gender dysphoria has
been associated with early-onset transsexualism
and favourable SR outcome (see Lothstein,
1982; Blanchard, 1985; Lindemalm et al. 1987 ;
Blanchard et al. 1989; Pfa
¨
fflin, 1992). Here, it is
the combination of factors that is crucial. Still,
the contradicting presence of more gender
dysphoria in childhood but less at application
should alert the clinician when assessing eligi-
bility. This inconsistency may reflect confusion
about development, an (unconscious) exagger-
ation of history if current feelings are not
clear-cut, or a conscious effort to mislead the
clinician.
Finally, we investigated which assessment
factors predicted post-operative functioning. It
is important to bear in mind that we applied a
continuous scale from good to bad, as opposed
to the dichotomy no regret ’–‘ regret ’, because
hardly any transsexuals reported regret. A non-
homosexual orientation, with more psycho-
pathology and dissatisfaction with secondary
sex characteristics predicted unfavourable post-
operative functioning. The finding that non-
homosexuals and those with more psychological
instability are at risk for unfavourable func-
tioning and more dissatisfaction after SR fits
with earlier studies (see Introduc tion ; Blanchard
et al. 1989; Lande
´
n et al. 1998). We found that
two non-homosexual s expressed regret about
SR. Finally, dissatisfaction with appearance
predicted poor post-o perative functioning,
either because it directly and adversely affected
psychological stabili ty or mood, or it indirectly
affected the way they were socially treated (or a
combination of both).
Taking all the findings into account, our
sample of clinicians appropriately assessed
some risk factors that predict the course and
outcomes of SR, yet they underestimated
others. They particularly recognized the impact
of the applicant’s psychological functioning and
physical appearance on post-operative func-
tioning. However, clinicians might want to take
special notice of MFs who report inconsistencies
in past and present gender dysphoria, in the
presence of psychopathology, and of non-
homosexuals with strong dissatisfaction about
their appearance and clear psychopathology.
They may benefit from additional guidance after
SR, while adjusting to their new lives and coping
with unexpected or adverse consequences.
The results of this study subscribe to the sig-
nificance of some of the risk factors described in
the literature with more conclusive data. Fur-
thermore, factors were found that could assist
clinicians in identifying individuals who might
be at risk for poor outcome.
ACKNOWLEDGEMENTS
The authors thank Mrs W. Harmsen and Mr
Jos Megens in particular for their invaluable
help in the data collection process and appreci-
ate the contribution of Dr Anton M. Verschoor
in the setting up of this research project. This
work was financially supported by the Stichting
Fondsenwervingsacties, the Ziekenfondsraad,
and the Stichting Nederlands Gender Centrum.
DECLARATION OF INTEREST
None.
NOTE
An Appendix accompanies this paper on the
Journal’s website (http//journals.cambridge.
org).
REFERENCES
APA (1994). Diagnostic and Statistical Manual of Mental Disorders
(4th edn). American Psychiatric Association: Washington, DC.
Arrindell, W. A. & Ettema, J. H. M. (1986). SCL-90 : Handleiding bij
een multidimensionele psychopathologie-indicator [SCL-90, Manual
98 Y. Smith et al.
of a multidimensional psychopathology-indicator]. Swets en Zei-
tlinger: Lisse, The Netherlands.
Blanchard, R. (1985). Typology of male-to-female transsexualism.
Archives of Sexual Behavior 14, 247–261.
Blanchard, R., Steiner, B. W., Clemmensen, L. H. & Dickey, R.
(1989). Prediction of regrets in postoperative transsexuals.
Canadian Journal of Psychiatry 34, 43–45.
Cohen-Kettenis, P. T. & Gooren, L. J. G. (1999). Transsexualism : a
review of etiology, diagnosis and treatment. Journal of Psycho-
somatic Research 46, 315–333.
Cohen-Kettenis, P. T. & van Goozen, S. H. M. (1997). Sex reassign-
ment of adolescent transsexuals: a fo llow-up study. Journal of the
American Academy of Child and Adolescent Psychiatry 36,
263–271.
Day, P. (2002). Tech Brief Series : trans-gender reassignment surgery.
New Zealand Health Technology Assessment Report 1, 1–38.
Derogatis, L. R., Lipman, R. S. & Covi, L. (1973). SCL-90: an
outpatient psychiatric rating scale preliminary report. Psycho-
pharmacology Bulletin 9, 13–27.
Doorn, C. D., Kuiper, A. J., Verschoor, A. M. & Cohen-Kettenis,
P. T. (1996). Het verloop van de geslachtsaanpassing: Een 5-jarige
prospectieve studie [The course of sex reassignment : A 5-year pro-
spective study]. Report for the Dutch National Health Council.
Doorn, C. D., Poortinga, J. & Verschoor, A. M. (1994). Cross-gender
identity in transvestites and male transsexuals. Archives of Sexual
Behavior 23, 185–201.
Eldh, J., Berg, A. & Gustafsson, M. (1997). Long-term follow up after
sex reassignment surgery. Scandinavian Journal of Plastic and
Reconstructive Surgery and Hand Surgery 31, 39–45.
Green, R. & Fleming, D. (1990). Transsexual surgery follow-up :
status in the 1990s. Annual Review of Sex Research 1, 163–174.
Kuiper, A. J. (1991). Transseksualiteit : Evaluatie van de geslachts-
aanpassende behandeling [Transsexualism: An evaluation of sex
reassignment]. Elinkwijk: Utrecht, The Netherlands.
Kuiper, A. J. & Cohen-Kettenis, P. T. (1998). Gender role reversal
among postoperative transsexuals. International Journal of Trans-
genderism 2 (http://www.symposion.com/ijt/ijtc0502.htm).
Lande
´
n, M., Wa
˚
linder, J., Hambert, G. & Lundstro
¨
m, B. (1998).
Factors predictive of regret in sex reassignment. Acta Psychiatrica
Scandinavica 97, 284–289.
Lawrence, A. A. (2003). Factors associated with satisfaction or regret
following male-to-female sex reassignment surgery. Archives of
Sexual Behavior 32, 299–315.
Lief, H. & Hubschman, L. (1993). Orgasm in the postoperative
transsexual. Archives of Sexual Behavior 22, 145–155.
Lindemalm, G., Ko
¨
rlin, D. & Uddenberg, N. (1987). Prognostic fac-
tors vs. outcome in male-to-female transsexualism: a follow up of
13 cases. Acta Psychiatrica Scandinavica 74, 268–274.
Lindgren, T. & Pauly, I. (1975). A body image scale for evaluating
transsexuals. Archives of Sexual Behavior 4, 639–656.
Lothstein, L. M. (1982). Sex reassignment surgery : historical,
bioethical, clinical and theoretical issues. American Journal of
Psychiatry 139, 417–426.
Lundstro
¨
m, B., Pauly, I. & Wa
˚
linder, J. (1984). Outcome of sex
reassignment surgery. Acta Psychiatrica Scandinavica 70, 289–294.
Luteyn, F., Kok, A. R. & van der Ploeg, F. A. E. (1980). NVM,
Nederlandse verkorte MMPI, Handleiding [Dutch short version of
the Minnesota Multiphasic Personality Inventory, Manual]. Swets
en Zeitlinger : Lisse, The Netherlands.
Mate-Kole, C., Freschi, M. & Robin, A. (1990). A controlled study of
psychological and social change after surgical gender reassignment
in selected male transsexuals. British Journal of Psychiatry 157,
261–264.
Meyer III, W., Bockting, W. O., Cohen-Kettenis, P. T., Coleman, E.,
DiCeglie, D., Devor, H., Gooren, L. J. G., Hage, J. J., Kirk, S.,
Kuiper, A. J., Laub, D., Lawrence, A., Menard, Y., Patton, J.,
Schaefer, L., Webb, A. & Wheeler, C. C. (2001). The standards of
care for gender identity disorders (6th Version). International
Journal of Transgenderism 5 (http://www.symposion.com/ijt/soc/
index.htm).
Molenaar, I. W. (1982). Mokken scaling revisited. Kwantitatieve
methoden 3, 145–164.
Pfa
¨
fflin, F. (1992). Regrets after sex reassignment surgery. Journal of
Psychology & Human Sexuality 5, 69–85.
Pfa
¨
fflin, F. & Junge, A. (1992). Geschlechtsumwandlung: Abhandlun-
gen zur Transsexualita
¨
t. Schattauer : Stuttgart, Germany.
Pfa
¨
fflin, F. & Junge, A. (1998). Sex Reassignment : Thirty years of
international follow-up studies SRS : A Comprehensive Review,
1961–1991 (English edn). Symposion Publishing : Du
¨
sseldorf,
Germany (http://www.symposion.com/ijt/pfaefflin/1000.htm).
Rakic, Z., Starcevic, V., Maric, J. & Kelin, K. (1996). The outcome of
sex reassignment surgery in Belgrade : 32 patients of both sexes.
Archives of Sexual Behavior 25, 515–525.
Rehman, J., Lazer, S., Benet, A., Schaefer, L. & Melman, A. (1999).
The reported sex and surgery satisfactions of 28 postoperative
male-to-female transsexual patients. Archives of Sexual Behavior
28, 71–89.
Ross, M. W. & Need, J. A. (1989). Effects of adequacy of gender
reassignment surgery on psychological adjustment : a follow-up of
fourteen male-to-female patients. Archives of Sexual Behavior 18,
145–153.
Spengler, A. (1980). Kompromisse statt stigma und unsicherheit.
Transsexuelle nach der operation [Compromises instead of
stigma and doubts. Transsexuals after surgery]. Sexualmedizin 9,
98–103.
Smith, Y. L. S., Cohen, L. & Cohen-Kettenis, P. T. (2002). Post-
operative psychological functioning of adolescent trans-
sexuals: a Rorschach study. Archives of Sexual Behavior 31,
255–261.
Smith, Y. L. S., van Goozen, S. H. M. & Cohen-Kettenis, P. T. (2001).
Adolescents with gender identity disorder who were accepted or
rejected for sex reassignment surgery: a prospective follow-up
study. Journal of the American Academy of Child and Adolescent
Psychiatry 40, 472–481.
van Goozen, S. H. M., Cohen-Kettenis, P. T., Gooren, L. J. G.,
Frijda, N. H. & van de Poll, N. E. (1995). Gender differences in
behavior: activating effects of cross sex hormones. Psychoneuro-
endocrinology 20, 343–363.
Van Tilburg, T. (1988). Verkregen en gewenste ondersteuning in het
licht van eenzaamheidservaringen [Received and desired support
related to the experience of loneliness]. Elinkwijk : Utrecht, The
Netherlands.
Verschoor, A. M. & Poortinga, J. (1988). Psychosocial differences
between Dutch male and female transsexuals. Archives of Sexual
Behavior 17, 173–178.
Wa
˚
linder, J., Lundstro
¨
m, B. & Thuwe, I. (1978). Prognostic factors in
the assessment of male transsexuals for sex reassignment. British
Journal of Psychiatry 132, 16–20.
Outcomes and predictors of sex reassignment 99
... Further, we have always acknowledged that results stemmed from only one sample and clinic, and that further research and replication are needed. It should be noted, however, that it is not only in this paper, but in a series of papers from the same clinic that determined that the adult transgender care approach, including affirming hormones (and surgeries), could effectively and safely be provided to minors, age 16 and up, as well (Cohen-Kettenis & van Goozen, 1997;Smith et al., 2001;Smith et al., 2005). These studies had positive outcomes. ...
... Levine et al. (2022) however observe difficulties in the 2014 study when it is noted that for the post-treatment assessment, the UGDS version of the experienced gender is used, instead of the birth-assigned gender. This was in line with the earlier studies at the CEDG (Cohen-Kettenis and van Goozen, 1997;Smith et al, 2001;Smith et al, 2005). In the design of these follow-up studies, the UGDS scales were 'flipped' as Levine states; at baseline according to the birth assigned gender, after treatment according to the experienced gender. ...
... The 'selection' however in the Participants section of the 2014 study does not describe that careful assessment, but the inclusion criteria (selection according to Levine et al., (2022)) of the participants. At the time, we were interested in those adolescents that had started puberty suppression before age 16 (affirming hormones below age 18 was evaluated in earlier studies (Cohen-Kettenis and van Goozen, 1997;Smith et al., 2001;Smith et al., 2005). Of the 196 consecutively referred adolescents, 140 adolescents were assessed eligible for medical intervention (71%, a proportion that has remained similar over almost two decades (Arnoldussen et al., 2020) and 111 (those below age 16) had started puberty suppression (the 29 adolescents who were age 16 years or older were prescribed sex affirming hormones). ...
Article
Adolescent transgender care is increasingly surrounded by controversies and criticism. One of these concerns expressed in a review article by Levine et al. entitled 'Reconsidering Informed Consent for Trans-Identified Children, Adolescents and Young Adults' is the limited evidence base, especially of the Dutch studies which provided the first and mostly cited basis for medical intervention at a young age. This Response is written by the first author of two of those studies that showed effectiveness of the approach that included puberty blockers. The author rebuts several of the concerns that Levine et al.have regarding these Dutch studies, among which are the limited statistical improvements of psychological measures, the use of the Utrecht Gender Dysphoria and the selection of participants. The author further refers to several shorter term longitudinal follow up studies that have been published, which are not mentioned by Levine et al.. They also show improvement or stable psychological functioning and relief of gender incongruence. Finally, a careful evaluation and informed consent provision has always been recommended in all editions of the WPATH's Standards of Care and are also part of the 8th version as well as the Endocrine Society guidelines. The author agrees therefore with Levine et al. that clinicians in transgender care should follow these international guidelines and provide such an assessment in order to ensure that medical interventions are appropriately provided for those transgender adolescents who need them.
... Transsexual people strive to change their bodies in order to be perceived externally in a way that is congruent with their gender identity [37]. The use of hypothalamic blockers to nullify the inconsistency between perceived gender and the development of secondary sexual attributes reduces the stress associated with gender role transition and provides the opportunity to socially present oneself as a member of the opposite sex [38]. However, most adolescents with gender dysphoria do not have access to the care and resources to be able to achieve this state of self-congruence and satisfaction for their own bodies [31]. ...
... Unfavorable outcomes of surgical gender reassignment in adults appear to be associated with late treatment rather than early intervention [41,42]. Studies evaluating the psychological functioning of adults and transsexual adolescents from the same clinic also found improved functioning among adolescents who had been treated early with hormone therapy [28,38,43]. The poorer psychological functioning in adults may result in part from the constant and lasting distress they have experienced throughout their lives. ...
... Suppression of puberty can be considered a diagnostic tool, as it saves time for both the adolescent, who can explore their gender identity without worrying about the development of secondary sexual attributes [22], and to the clinician, who can better understand the nature and intensity of adolescent distress [23] to arrive at a more precise diagnosis [20]. Many studies have found an improvement in functioning and psychological well-being after treatment with GnRH analogues [25][26][27][28][29][30][31][32][33][34][35][36][37][38]. When, on the other hand, therapy is denied, and the adolescent resorts to self-medication, he is no longer followed by professionals in the sector, with the foreseeable physical and psychological repercussions that follow (wrong methods and dosages of administration, possible infections due to injections that do not comply with appropriate hygiene standards), [12,39]. ...
Chapter
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Gender identity does not always develop in line with biological sex. Gender dysphoria at young age implies a strong incongruence between gender identity and the assigned sex; the rejection of one\'s sexual attributes and the desire to belong to the opposite sex; and a significant clinical suffering or impaired individual functioning in life spheres. The purpose of this chapter is a narrative review of the literature available on puberty suppression therapy through GnRH analogues. Biological puberty provides intense suffering to the adolescent with gender dysphoria who does not recognize himself in his own body. These drugs suppress the production of endogenous gametes and sex hormones. Although the effects of therapy are reversible, and biological development resumes spontaneously once the medication is stopped, the administration of GnRH analogues at a young age has fueled a scientific debate on the matter of the ethics of pharmacological intervention with minors. In conclusion, the studies considered show that GnRH analogues do not have long-term harmful effects on the body; prevent the negative psychosocial consequences associated with gender dysphoria in adolescence (suicidal ideation and attempts, self-medication, prostitution, self-harm); improve the psychological functioning of young transsexuals; and are diagnostic tools that allow adolescents to buy time to explore their gender identities.
... Mais aucun·e jeune n'a exprimé de regrets. Si la question des regrets est souvent source d'inquiétude, particulièrement pour les parents, la plupart des études menées à ce sujet observent de faibles taux de regrets (inférieurs à 2 % pour les cohortes quantitativement significatives) chez les patient·e·s ayant suivi des traitements de réassignation sexuelle, que ce soit à court ou long terme (Olson-Kennedy, Warus, Okonta, Belzer et Clark, 2018;Wiepjes et al., 2018;Smith, Goozen, Kuiper et Cohen-Kettenis, 2005;Cohen-Kettenis, Schagen, Steensma, de Vries, 2001;Pfäfflin, 1993). ...
Article
The past decade has witnessed significant change in medical care for trans youth. A well-established pathologizing approach focused on asserting a young person’s assigned gender has been challenged by a growing number of experts who favour a model that supports gender exploration (e.g., by providing access to hormonal treatments and puberty blockers). Based on interviews with 36 parent-youth dyads (72 interviews in total), this article explores the expectations and impacts associated with medical transition. On the one hand, the interview data show that young people and their parents agree that access to trans-affirmative medical care has a positive impact on youth development. Specifically, it is seen to reduce suffering associated with gender dysphoria, while promoting both self-recognition and intersubjectivity. On the other hand, the interview data highlight the extent to which available health care pathways (often based on a binary approach) have failed to keep pace with the expectations and concerns of youth and their parents. Our article therefore emphasizes the importance of offering transaffirmative care adapted to the needs of youth seeking to transition.
Article
Some Christians are anxious and uncomfortable about gender diversity and transition. Sometimes, they understand these issues as a rejection of God's intention for creation. Gender diversity has also been assumed to entail self-deception, mental ill-health, and dysphoria. Yet, humans are inherently transformative creatures with a vocation to shape their own worlds and traditions. Transformative creaturely theology recognizes the capacity of gender to shape humans even as we also question it. In this book, Susannah Cornwall reframes the issues of gender diversity and transition in constructive Christian theological terms. Resisting deficit-based discourses, she presents gender diversity in a way that is positive and non-oppositional. Her volume explores questions of the licit limits of technological interventions for human bodies, how gender diversity maps onto understandings of health, and the ethics of disclosure of gender diversity. It also brings these topics into critical conversation with constructive Christian theologies of creation, theological anthropology, Christology, and eschatology.
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Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
Article
Background: Gender-affirming surgery is becoming more common among reconstructive surgeons. Bibliometric analyses are statistical evaluations of published scientific correspondence and are a validated method of measuring influence in the scientific community. As no such bibliometric analysis has been done as of yet, the purpose of this study is to identify the characteristics of the 50 most-cited peer-reviewed articles on gender-affirming surgery. Methods: The Scopus abstract and citation database was utilized in April 2020 to search for English-language publications related to gender-affirming surgery. The 50 most-cited publications that met inclusion criteria were reviewed for various metric tabulations. Results: The 50 publications have been cited a total of 4402 times. Thirty-one (62%) were published in 2000 or later. Phalloplasty was the most discussed surgical technique, and 18 of the articles focused on female-to-male (FtM) patients. Case series (46%) and review articles (24%) were most common and there were no Level I or Level II studies. The Netherlands contributed the most, with 13 articles. Among the most frequent keywords in the 50 abstracts were “flap” and “complication”. The earliest author keywords used were “transsexual” and “sex reassignment”. Conclusions: The keyword usage in these abstracts over time seems to follow the trend of a more socially inclusive lexicon. A focus on studies with a higher level of evidence may optimize surgeon education and more appropriately guide clinical practice. This study reveals that the most influential and commonly referenced studies may not be sufficient to appropriately guide clinical practices.
Article
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Although sex reassignment surgery (SRS) is an effective treatment method with largely successful results, clinicians occasionally come across persons who regret their decision to undergo SRS. This regret can be inferred from their overt behavior, such as a second social role reversal, or their statements that they regret the steps they have taken. However, their statements and behavior do not always correspond. By means of a semistructured interview, we have extensively interviewed 10 persons who reported feelings of regret or whose overt behavior indicated a significant degree of non-successful postoperative functioning, possibly associated with regret. It appeared that the majority of this group had a (very) late start of cross-dressing and serious psychological problems, which do not merely seem to be a result of their gender dysphoria, before requesting SRS.
Article
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Using data draw from the follow-up literature covering the last 30 years, and the author's clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author's sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.
Article
Reviews follow-up literature from 1979–1989 on both male-to-female and female-to-male postoperative transsexuals. Preoperative factors indicating a favorable outcome included the following: reasonable degree of mental and emotional stability shown in life history with no psychosis, successful adaptation in the desired role for at least 1 yr, with convincing physical appearance and behavior; sufficient understanding of the limitations and consequences of surgery; and preoperative application of psychotherapy. Surgical adequacy was found to be a major factor in favorable outcome. The lack of reported standardized selection criteria for surgery and the infrequent use of standardized outcome instruments and rating criteria make follow-up conclusions difficult. It is suggested that follow-up measures be improved by incorporating more detailed autobiographical accounts. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
In order to illustrate the particular circumstances which weigh against the prospect of a successful result of sex reassignment, the authors describe 5 male cases of transsexualism, all of whom subsequently regretted the measures taken for sex reassignment. The number of factors suspected to be prognostically unfavorable was to a statistically significant degree more common among 5 "repentant" cases than among 9 cases with favorable outcome. It was also evident that the patients with unfavorable outcome were considerably older when they first sought help with the aim of obtaining sex reassignment. Results suggest that the more of such factors there are present in a particular case the stronger are the reasons for restraint in embarking on a course of active intervention. (PsycINFO Database Record (c) 2012 APA, all rights reserved)