\doc\web\99\12\transex.txt Date sent: Tue, 24 Aug 1999 20:42:07 -0400 To: H-Bd@egroups.com From: Ray Blanchard Subject: [h-bd] Sex Reassignment Surgery List members: I do not have time to write a specific response to Linda Chavez's comments regarding sex reassignment surgery, because I am packing to leave for a trip tomorrow. In lieu of that, I am appending below a brief (1,700 word) article that I wrote for a Canadian psychiatry newsletter. Because this article was written as a reply to a preceding article, some of the emphases may seem a little odd, but it covers the main points that need making. THE PARAGRAPH HEADINGS SET OFF BY ASTERISKS REFER TO ISSUES RAISED IN THE ARTICLE TO WHICH I WAS REPLYING, NOT TO MY OWN OPINIONS! ************************************************ The Case for Publicly Funded Transsexual Surgery Ray Blanchard, Ph.D. Head, Clinical Sexology Program, The Centre for Addiction and Mental Health; and Department of Psychiatry, University of Toronto In his thoughtful article, Dr. Fedoroff has raised a number of issues about sex reassignment that merit serious consideration. In what follows, I will attempt to respond to his specific points and to defend the standard view of mental health professionals involved in the clinical management of gender-dysphoric patients. Nosological Position of Transsexualism *Transsexualism is a short-lived diagnosis* Transsexualism is an ancient and wide-spread phenomenon. The hijras of India, for example, are a traditional community of men who dress and live as women and earn their living as entertainers, in particular, by singing and dancing at weddings, childbirth celebrations, and so on. Acceptance into the hijra community involves ritual castration and penectomy (Nanda, 1984). Transsexualism was first recognized as a specific psychiatric disorder in the DSM-III. The diagnostic label, "Transsexualism" was eliminated from the DSM-IV in favor of the broader term, "Gender Identity Disorder," which applies to all persons who would previously have been diagnosed as transsexuals as well as those with milder or remitting forms of gender dysphoria. This terminological change was a consequence of the effort to harmonize the diagnostic criteria for gender identity disorders in adults and in children (whom one would be reluctant to label as "transsexual"). Thus, transsexualism has not been "removed" from the DSM, as is sometimes misunderstood; it has simply been renamed. The ICD-10, which also lists gender identity disorders as specific psychiatric disorders, retained the term "transsexualism." *Transsexualism is a delusional disorder* The phrase, "A woman trapped in a man's body" ("Anima muliebris in corpore virili inclusa") was originally used to describe male homosexuality (Ulrichs, 1868). Transsexuals seized upon this phrase as the only language available for explaining their predicament to themselves and for communicating their feelings to others. The great majority of patients understand full well that this is a facon de parler, not a literal statement of fact, and are not delusional in any normal sense of the word. *Transsexualism is an overvalued idea* I have never heard a patient say "No one will love me until I have breasts," but if I did, I might have to concede he has the data on his side. Blanchard, Steiner, and Clemmensen (1985) found that postoperative transsexuals with breast implants were more likely to be cohabiting with a male partner. Leaving aside my specific response to Dr. Fedoroff's specific example, I do not think transsexualism meets the criterion of an overvalued idea. What sets transsexuals apart from the majority is not that the majority are less invested in the idea of changing sex, but that the majority do not entertain this notion at all. *Transsexualism is a variant of normal gender identity or a lifestyle choice* These arguments have been advanced in recent years by a few transsexual activists, who wish to avoid the stigma of being diagnosed with a mental disorder. The notion that transsexualism is merely an extreme variant of gender identity is specious. The number of adults who are unsure what sex they are, or should have been, or would like to be, is vanishingly small. Gender identity is not distributed along some bell-curve, with transsexuals representing one tail of the distribution, and persons completely contented with their sex representing an equally tiny proportion at the other end. The notion that transsexualism is a life-style choice is equally absurd. The "choices" confronting transsexuals are whether to endure a lifetime of frustration and misery, kill themselves, or risk--and often lose--their families, friends, and jobs in hopes of finding a happier life as the opposite sex. That is hardly analogous to deciding whether to rent an apartment downtown or buy a house in the suburbs. *Transsexualism is a physical disease* A few studies on homosexual males (Allen & Gorski, 1992; LeVay, 1991) raise the possibility that transsexualism might, at the neuroanatomic level, literally represent a type of intersexuality. Such a conclusion would certainly change the complexion of the nosological debate. One might then ask who is more delusional--the transsexuals who claim they are "women trapped in men's bodies" or the person who continues to insist they are not. At present, however, the empirical data are lacking to decide this matter one way or the other. *Transsexualism is what?* If transsexualism is not a delusion, an overvalued idea, a normal variant, or a lifestyle choice, then what is it? A gender identity disorder, as Gertrude Stein might have said, is a gender identity disorder is a gender identity disorder. It is not, nor does it have to be, a subtype, species, or exemplar of any other psychiatric disorder, psychological state, or sociological phenomenon. It is sui generis and was recognized as such by the framers of the DSM-III, who placed it in its own section: Gender Identity Disorder. What forms of treatment are or are not appropriate for other types of psychiatric disorders is simply not relevant. Surgical Treatment of Transsexualism The clinical management of transsexualism has always been a purely empirical, trial-and-error undertaking. Sex reassignment surgery has continued to be one of its treatment modalities partly because nothing better has come along to replace it and partly because the bulk of available evidence indicates that it does enable patients to live more comfortably with their gender identity disorder. It is important to understand that, at reputable gender identity clinics, sex reassignment is not the first treatment offered to patients but rather the last. At the CAMH Gender Identity Clinic, for example, patients are required to live full-time as the opposite sex for two years before they are even considered eligible for surgery; our requirements further specify that patients must work, attend school, or perform bona fide charity work in the cross-gender role during this trial period, and that they must provide us with documentation proving they have done so. This requirement alone screens out the 80% of new referrals whose gender dysphoria is clearly not strong enough to merit sex reassignment and gives the other 20% plenty of time to decide whether life in the cross-gender role is, in fact, a substantial improvement over life in their original gender role. The positive outcomes described below partly reflect the fact that mental health professionals have traditionally been very conservative in approving patients for sex reassignment surgery. *Therapeutic impact of sex reassignment surgery* Several reviews of the treatment outcome literature have concluded that sex reassignment surgery alleviates emotional distress and improves psychosocial adjustment in transsexuals (e.g., Abramowitz 1986; Blanchard & Sheridan, 1990; Lundström 1981; Pauly 1981). Individual studies have examined various areas of functioning. Sex reassignment surgery has been shown to be associated with improvements in psychiatric symptomatology, especially anxiety and depression (Blanchard et al., 1985; Mate-Kole, Freschi, & Robin, 1988, 1990), with improvements in patients' love relationships and sex lives (Blanchard, 1985; Fahrner, Kockott, & Duran, 1987; see also Kockott & Fahrner, 1987, 1988), and with improvements in patients' social lives (Mate-Kole et al., 1990). The effect of sex reassignment surgery on patients' economic circumstances is more complicated. Better economic adjustment appears to be associated with the male gender role, regardless of the transsexual's biological sex, and regardless of whether this is the role of choice. Therefore, the socioeconomic consequences of sex reassignment are more positive for female-to-male than for male-to-female transsexuals (Blanchard, 1985; Blanchard et al., 1985). *Consumer satisfaction* One of the most striking and consistent findings in the surgical outcome literature is the overwhelming proportion of transsexuals who express satisfaction with their decision to undergo sex reassignment surgery. Blanchard, Steiner, Clemmensen, and Dickey (1989), for example, investigated 111 postoperative transsexuals who had been surgically reassigned for at least one year, representing a follow-up rate of 84%. The mean follow-up interval was 4.4 years. Only 4 patients expressed regrets, leaving a satisfaction rate of 96%. If patients' claims of greater happiness were accompanied by objective evidence to the contrary--frequent suicide attempts, psychiatric hospitalizations, general deterioration in social relationships--one would be justified in dismissing their self-reports as the result of denial or cognitive dissonance reduction. As I indicated in the previous section, however, the objective evidence, far from belying patients' reports of satisfaction with surgery, tends to confirm them. It therefore appears that patients' hopes of a happier life in the cross-gender role are, in fact, realized. *Treat or wait?* If a non-surgical cure for transsexual feelings were within sight--say three or four years away--attending clinicians should and would advise their transsexual patients to wait for that cure rather than undergo irreversible and merely palliative treatment. The reality is that we are perhaps decades away from the most basic scientific understanding of normal gender identity development, let alone any prospect of treatments that would reverse cross-gender identity in transsexual adults. To recommend to patients presenting today that they accept no treatment short of a "cure" is to recommend that they relinquish their hopes for salvaging a blighted and tragic life--something few of us would willingly accept for ourselves or for our families. *Rationale for public funding* The reasons for treating psychiatric disorders are so obvious that they are rarely discussed--certainly the alleviation of human suffering, perhaps also enhancement of patients' ability to contribute to society, or a reduction of the burden they place on their families. The ability of reassignment surgery to accomplish these goals, especially the first, compares favorably with that of many other psychiatric treatments and is therefore equally deserving of public funding. Summary and Conclusions 1. Transsexualism is recognized as a psychiatric disorder by the American Psychiatric Association and by the World Health Organization. 2. Sex reassignment surgery is the treatment of last resort for transsexuals who cannot achieve peace of mind in their original gender role. 3. There is ample evidence that sex reassignment improves transsexuals' psychosocial adjustment, in particular, their mood and morale. 4. The overwhelming majority of patients express satisfaction at their decision to undergo sex reassignment. 5. The fact that sex reassignment surgery is a palliative treatment rather a cure is not a rationale for withholding it. 6. As an effective treatment for a specific mental disorder, sex reassignment surgery is as deserving of public funding as any other psychiatric treatment. References Abramowitz, S. I. (1986). Psychosocial outcomes of sex reassignment surgery. Journal of Consulting and Clinical Psychology, 54, 183-189. Allen, L. S., & Gorski, R. A. (1992). Sexual orientation and the size of the anterior commissure in the human brain. Proceedings of the National Academy of Sciences of the United States of America, 89, 7199-7202. Blanchard, R. (1985). Gender dysphoria and gender reorientation. In B. W. Steiner (Ed.), Gender dysphoria: Development, research, management (pp. 365-392). New York: Plenum Press. Blanchard, R., & Sheridan, P. M. (1990). Gender reorientation and psychosocial adjustment. In R. Blanchard & B. W. Steiner (Eds.), Clinical management of gender identity disorders in children and adults (pp. 159-189). Washington, DC: American Psychiatric Press. Blanchard, R., Steiner, B. W., & Clemmensen, L. H. (1985). Gender dysphoria, gender reorientation, and the clinical management of transsexualism. Journal of Consulting and Clinical Psychology, 53, 295-304. Blanchard, R., Steiner, B. W., Clemmensen, L. H., & Dickey, R. (1989). Prediction of regrets in postoperative transsexuals. Canadian Journal of Psychiatry, 34, 43-45. Fahrner, E.-M., Kockott, G., & Duran, G. (1987). Die psychosoziale Integration operierter Transsexueller [The psychosocial integration of postoperative transsexuals]. Nervenartz, 58, 340-348. Kockott, G., & Fahrner, E.-M. (1987). Transsexuals who have not undergone surgery: A follow-up study. Archives of Sexual Behavior, 16, 511-522. Kockott, G., & Fahrner, E.-M. (1988). Male-to-female and female-to-male transsexuals: A comparison. Archives of Sexual Behavior, 17, 539-546. LeVay, S. (1991). A difference in hypothalamic structure between heterosexual and homosexual men. Science, 253, 1034-1037. Lundström, B. (1981). Gender dysphoria: A social-psychiatric follow-up study of 31 cases not accepted for sex reassignment. (Report from the Department of Psychiatry and Neurochemistry, St. Jörgen's Hospital, University of Göteborg). Hisings Backa, Sweden: University of Göteborg. Mate-Kole, C., Freschi, M., & Robin, A. (1988). Aspects of psychiatric symptoms at different stages in the treatment of transsexualism. British Journal of Psychiatry, 152, 550-553. 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. Nanda, S. (1984). The hijras of India: A preliminary report. Medicine and Law, 3, 59-75. Pauly, I. B. (1981). Outcome of sex reassignment surgery for transsexuals. Australian and New Zealand Journal of Psychiatry, 15, 45-51. Ulrichs, K. H. (1868). Memnon. Schleiz: Hübscher. <<<<<<<<<<<<<<<<<<<< >>>>>>>>>>>>>>>>>>>> Ray Blanchard, Ph.D. Head, Clinical Sexology Program CAMH--Clarke Division 250 College Street Toronto, Ontario M5T 1R8 Canada Phone: (416) 979 4747, Extension 2436, or (416) 979 2221, Extension 2436 Fax: (416) 979 6965