Gender Role Reversal among Postoperative Transsexuals

By A.J. Kuiper, Ph.D. and P.T. Cohen-Kettenis, Ph.D.

Citation: Kuiper A. J. and Cohen-Kettenis P.T. (1998) Gender Role Reversal among Postoperative Transsexuals. IJT 2,3, http://www.symposion.com/ijt/ijtc0502.htm

• Abstract
• Introduction
• Method
• Results
• Discussion
• Epilogue
• References
• Appendix

Abstract

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.
  

Introduction

Sex reassignment surgery (SRS) is an effective method to treat the most extreme form of gender dysphoria, often referred to as transsexualism. Overall satisfactory post-operative results are reported of 87% for male-to-female transsexuals (MFs) and 97% for female-to-male transsexuals (FMs) (Green and Fleming, 1990). However, the treatment is not equally successful in all cases. In spite of strict prior selection and counseling during the treatment, an estimated 1 to 2 percent of those treated express regret about the SRS, be it for different reasons.

In an extensive review of follow-up studies, Pfåfflin and Junge (1992), have found 20 cases of MFs and 5 FMs (probably 18 and 4, because three cases were mentioned in more than one study), who during the sex reassignment procedure, returned to their original gender role or showed other clear signs of regret. Three factors might have contributed to the reversal: first, doubts about the correctness of the diagnosis; second, doubts about the feasibility of the role reversal and third, the quality of the surgical interventions.

Up until now, few systematic studies regarding the negative outcomes of the SRS have been conducted. Only a few authors have made empirical efforts to track down such factors (Walinder et al., 1975; Lindemalm et al., 1987; Blanchard at al., 1989; Bodlund and Kullgren, 1996; Pfäfflin, 1992). More than 20 possible risk factors that influence the result of SRS negatively, are mentioned throughout the literature. However, none of them has proved to be an absolute contra-indication for SRS. Negative prognostic factors tend to lie in the area of psychological dysfunction, family background, sexual orientation, disrupted social contacts, insufficient professional support during the 'real life test', and complications of surgery. As it appears from Pfåfflin and Junge's overview, the number of persons per study who openly regret SRS is rather low. However, based on our own and the extensive clinical experience of other colleagues with several hundreds of transsexuals, we know that a very small number of people regret their decision.

More insight into the characteristics of persons with postoperative regret would facilitate future selection of those applicants who are eligible for SRS. One way of detecting risk factors is to relate, in prospective or post hoc follow-up studies, preoperative characteristics to possible postoperative regrets. However, as appears from Pfåfflin’s and Junge’s overview, regretful persons tend not to show up in such studies. Another approach is to actively search for regretful postoperative individuals and to try to systematically describe their life and treatment histories. This article presents the results of such a study in the Netherlands.

Regret: a heterogeneous term
Although the term 'regret' primarily refers to the situation in which someone wants to totally undo the results of SRS, it is not limited to this situation. Evidence for feelings of regret, ranging from 'unmistakably certain' to ' likely' can be distinguished. Because it must be very difficult to acknowledge significant doubts or feelings of regret after having made such an important decision in life, some individuals, for example, will not easily express such feelings, even if their behavior strongly points in that direction. With respect to the postoperative situation we therefore distinguish four possible signs of regret. Gender role behavior and the verbal expression of regret are relevant dimensions. (table 1):

1. individuals openly express regret about their decision to undergo SRS, and they have returned to living in their former gender role and/or apply for a second SRS.

2. individuals who have undergone SRS may express the feeling that they would never consider SRS again, when in the same position as before treatment, or even express regret on their decision, but may not make any attempt for gender role reversal.

3. individuals do not live any longer in the previously desired sex, but do not express any regret. Some may even state that they are happy about their decision, and still consider themselves transsexuals, but choose to live in the original gender role again for social reasons.

4. individuals may not openly express any feelings of regret with respect to their SR process, nor make any attempt to reverse their current situation, but clinicians, relatives, or others may attribute unfavorable social and/or psychological circumstances (e.g. feelings of loneliness, suicide attempts or psychiatric problems) to feelings of regret.

We aimed our study at the first three groups, because regret statements and overt behavior are not necessarily concordant. Moreover, the behaviors mentioned in category 4 may actually be manifestations of regret, or be indicative of other underlying problems. They do not seem to be reliable enough indicators of regret.
  

Method

Procedure
The subjects for the study were traced in three different ways: by advertising in national newspapers/magazines, by making the study known among self-help groups of transsexuals, and by inviting patients of the Amsterdam gender team, known to live again in their former gender role.

When someone agreed upon participation in the study, arrangements were made for an interview. All subjects chose to be visited at home for the interviews, which lasted for 3 hours on average.

At the time of the study around 1100 transsexuals (800 MFs and 300 FMs) had undergone SRS in the Netherlands. The Amsterdam gender team had medically treated 95% of them. Until two years before the study most of the applicants were seen and diagnosed by a few private working clinicians from outside the team.

Instrument
For the purpose of this study a semi-structured questionnaire was developed. It consisted, among other things, of questions on gender identity and gender role development, history of cross-dressing, sexuality, psychiatric history in the past and the present, the initial reason for applying for SRS, the way the diagnostic process proceeded before and during SRS, and questions about realizing, explaining and coping with feelings of regret.
  

Results

Subjects
All together we obtained data from 9 MFs and 1 FM (table 2). None of the subjects had been patients of the interviewers.

The mean age of the ten subjects was 46 years. They applied for SRS on average 11 years before the interview when they were on average 35 years old. All but one subject had been seen by the clinicians working outside the Amsterdam gender team. After application, it took on average more than one-and-a-half years before the diagnostic procedure was completed and the decision about the SR was made. Some subjects received the permission to start hormone treatment rather quickly, whereas in others the decision-making took much longer (range 0.2 years - 8 years). The 'real-life-test' thereafter lasted slightly more than 2 years. Eight MFs underwent vaginoplasty, one MF only had been castrated. The FM underwent mastectomy, hysterectomy and oophorectomy when she was 27 years old. Further operations were not performed.

On average, the first significant signs of a disturbed reassignment became clear 1.4 years after the sex-operation.

The mean time between these first feelings of regret and the time of the interview was 6.6 years.

Current status - gender identity and gender role
Seven subjects, including the FM, reported, to have, at some point in their lives, changed their gender identity towards their former biological status (table 3). One person (MF) felt stable and confident in the new gender, one person felt in-between, and one person reported to have a fluctuating gender identity.

Seven subjects, including the FM, had decided to live again permanently in their former gender role. Two MFs showed fluctuating gender role behavior. Sometimes they lived as a woman, sometimes as a man. The only MF with a stable female gender identity leads a double life. On request of his wife and his six children this elderly person lived at home as a woman, but publicly as a man.

Regret
With the exception of one MF not one person would ever decide again to start with the sex reassignment procedure (table 4). They now think that it did not solve their real problems. It is remarkable that three of them (3 MFs) did not feel any regret on the fact that they had undergone SRS. They stated that this apparently must have been the way they had to go.

Attributions of 'regret'
Five male persons living again as men, and the female person living again as a woman, responded spontaneously to the question about their ideas about reasons for regret that the wrong diagnosis had been made and thus the wrong treatment was given (table 5). Six persons clearly ventilated their feelings of regret about the decision; three of them accused their clinician of incompetence. Four others respectively gave as primary reasons: social isolation, disappointing surgical results and a sudden vanishing of the urge to live as a woman.

Doubts before or during SRS
Seven subjects already had doubts before or during the SR procedure (table 6), but five of them only expressed them postoperatively. They didn't dare to share their feelings with their psychologist or psychiatrist, as they were afraid that it would put the SRS at risk. Two MFs reported, even before the start of the SR procedure, to their clinician to have significant doubts about the correctness of the decision to undergo the sex reassignment. One felt driven by his former partner to become a woman and claimed never to have had a female gender identity. He never expressed his doubts. The other MF feared the future, because of his very poor social conditions. He said to have showed his hesitations to his psychologist, but had been reassured by him.

The other five doubters reported not to have had doubts about the treatment itself, but about the 'leap into the dark'.

Development of the gender conflict
Five subjects had their first cross-gender feelings in childhood (table 7). The other five persons had this experience on a much later age. Furthermore, 7 MFs and the one FM started cross-dressing only after the beginning of puberty; the other 2 MFs incidentally cross-dressed before puberty. For one person the cross-dressing had always been associated with sexual arousal.

It is very notable that with exception of 1 MF and the FM no person showed distinct atypical gender role behavior during their childhood.

Psychological functioning before SRS
All persons had consulted a psychologist or psychiatrist on one or more occasions before they applied for SRS (table 8). On basis of their own reports, this happened for different reasons: feelings of depression, gender identity problems, relational problems, alcohol abuse and psychotic episodes. Eight persons had suicidal thoughts and four of them had tried to commit suicide. The authors did not have at their disposal the standardized pre-treatment data of the subjects’ psychological functioning.

Alternative explanations
On the basis of the available data from this study (consisting of course primarily of post hoc self-report information) the initial diagnoses ('Transsexuality' according DSM-III-R) were reconsidered by the authors. By doing so we have tried post hoc to verify the appropriateness of the original diagnoses. Apart from the biographical data, special attention was given to: the development of (cross)gender identity and gender role (early and late onset), (the motives for) cross-dressing, the psycho-sexual development, body-satisfaction, present and past psychiatric history, the manifestation of the wish to undergo SRS, expectations towards the results of the SR process.

Some more information can be found in the case descriptions in the appendix of this article.

Using this information we now have come to the following alternative explanations.

1. two transsexuals (DSM-IV: Gender Identity Disorder 302.85): one of the early onset type and one with late onset characteristics (subjects 5 + 6)

2. two persons with non-transsexual gender identity disorders (DSM-IV: Gender Identity Disorder NOS 302.9): late onset gender dysphoric feelings, strongly related to stressful experiences (subjects 1 + 7)

3. four persons with general identity problems (DSM-IV: Identity Problem 313.82) that were confused with gender identities disorders (subjects 2 + 4 + 9 + 10)

4. one fetishistic transvestite (DSM-IV: Transvestic Fetishism 302.3) (subject 8)

5. one homosexual man with a weak male gender identity, who came to his wish for SRS by severe coercion of his former partner (subject 3)

In retrospect, in our opinion all persons have been suffering from severe identity conflicts at the moment they applied for SRS. However, with exception of the subjects 5 and 6, it seems that eight of the persons did not suffer from extreme gender dysphoric feelings related to a genuine, irreversible cross-gender identity/role development. This, being the main criterion for starting a sex-reassignment procedure, could be an explanation for the fact that these persons at the end did not feel relieved by the SRS.
  

Discussion

Conclusions from this study should be drawn with caution. In the first place the data in the study have not been compared to a matched control group of successfully functioning transsexuals. This makes it impossible to pinpoint the specific characteristics of the regretful group. In the second place, it is not exactly known how many SRS treated individuals in The Netherlands do have postoperative regrets. Thus we have no scale on which to gauge the representativity of the subjects studied for the group of regretters as a whole.

From the interviews with this small and perhaps selective group it seems that in the vast majority of the cases the correctness of the original diagnoses/explanations is questionable, and thus so is the performed SRS. For instance, almost no one reported extreme atypical gender role behavior during childhood. This places our cases among the late to very late manifestations of gender dysphoria. It is assumed that late onset gender dysphoria itself may be a risk factor (Lothstein, 1982; Blanchard, 1985; Pfäfflin, 1992), certainly if there are plausible psychological explanations for the arisal of the gender dysphoria. In our opinion, for five subjects there were such explanations (subjects 1, 2, 3, 7 and 9). In these cases, psychotherapeutic or other non-medical treatment exploring the request for SRS as a solution for their problems should probably have been the treatment of choice.

The fact that the real-life test did not filter out these future regretters, probably has to do with the subjects not expressing any doubts and/or the clinicians not being aware of subtle signs of doubts. Although the 'real-life test' is a very useful and essential supplementary diagnostic instrument, our findings show that it is not watertight. This is especially the case when the applicant does not honestly inform the clinician about his feelings and motives.

A system for corroboration may seem to be a solution but, attractive as such a system may look, it also has its disadvantages. It places the clinician/diagnostician in the role of a controller and changes the relationship between mental health professional and applicant. Instead of a safe situation where confusions and uncertainties can be expressed and explored, which is a necessary condition for getting relevant information in the diagnostic phase, the relationship becomes one in which applicants have to 'prove' their transsexualism, by means of documents or witnesses. In such a atmosphere it is likely that the observed missing of meaningful clues by the clinician and non-reporting of significant facts (or even deceit) by the applicant will result in more instead of less regret cases.

How can the risk of false-positive decisions possibly be reduced? Our study underlines the need for caution in the treatment of gender dysphoric individuals if there is a combination of several risk factors such as stress-related late onset of the gender conflict, fetishistic cross-dressing, psychological instability and/or social isolation. Care, provided by a gender team in which professionals of different disciplines interact intensively, may be of help in this difficult field. Signs that may be missed by, for instance, the psychologist/psychiatrist may be noted by the endocrinologist and communicated to the psychologist/psychiatrist. In difficult cases referral for hormone treatment can be extensively discussed among psychologists and psychiatrists. In a multidisciplinary team, the risk of decisions based on personal views of one individual or insufficient information, because only one discipline was involved, seems to be significantly reduced. Futhermore, it may be of help if diagnosis and treatment follow a standard protocol, such as the Standards of Care of the International Harry Benjamin Gender Dysphoria Association.

The outcome of this group of individuals, all supposedly regretful at the start of the study, illustrates the diversity of the concept of regret. Reasons for 'regret' diverge and so does postoperative coping (e.g. gender role behavior). When describing 'poor outcome' in follow-up studies a more in depth analysis of such outcome is warranted.
  

Epilogue

While reporting about the results of our study in this article, now two years after the last interview, we can mention that some of the subjects have continued the their course, while others have changed their situation again. The only FM lives permanently as woman with a male partner. She underwent breast augmentation and feels relatively happy and stable. One MF (subject 9) underwent mastectomy. He is not happy about that, but feels it had to be done to live more properly socially as a male person. Subject 5 does not live anymore in a double role, but lives permanently as a woman. Subject 3 decided to keep on living as a woman and married recently. The social and physical situation of the other six persons has been unchanged.

These additional findings again illustrate the complexity of regret in postoperative transsexuals.
  

References

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.

Bodlund, O. & Kullgren, G. (1996). 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.

Green, R. & Fleming, D. (1990). Transsexual surgery follow-up: status in the 1990s. Annual Review of Sex research, 7, 351-369.

Lindemalm, G., Körlin, D. & Uddenberg, N. (1987). Long-term follow-up of 'sex change' in 13 male-to-female transsexuals. Archives of Sexual Behavior, 3, 187-210.

Lothstein, L.M. (1982). Sex reassignment surgery: historical, bioethical, and theoretical issues. American Journal of Psychiatry, 139, 417-426.

Pfäfflin, F. (1992). Regrets after sex reassignment surgery. Journal of Psychology and Human Sexuality, 5, 69-85.

Pfäfflin, F. & Junge, A. (1992). Nachuntersuchungen nach Gesclechtsumwandlung - Eine kommentierte Literaturübersicht 1961-1991. In: Pfäfflin F, Junge A, red. Geschlechtsumwandlung - Abhandlungen zur Transsexualität. Schattauer, Stuttgart - New York, 149-457.

Wålinder, J. & Thuwe, J. (1975) A social-psychiatric follow-up study of 24 sex-reassigned transsexuals. Reports from the psychiatric research centre, St. Jörgen's Hospital, University of Göteborg, Sweden.
  

APPENDIX

Short descriptions of the 10 interviewed persons.

1. MF. Age: 37
Lives as a man again with female partner (ex-wife) and their son. No job. He had unstable family circumstances (mother had psychological problems, family moved many times from one place to another).

First cross gender behavior at 22, first strong cross gender feelings and wish for SRS at 25. Aversion against sexuality. Had psychotic decompensation around 18, but did not receive treatment. Suicide attempt at 16. Had counseling because of work-related problems for one year. Aversion against sexuality.

Diagnostic phase took 18 months. After start of hormones two year real life test. Physical effects of hormones were disappointing and he had manic depressive episodes. Had doubts. Did not report his doubts nor his depressions to his psychologist. Social consequences of SRS were very stressful. Feels better after returning in male gender role. Regrets SRS. Does not really feel like a man, woman or transsexual. Feels sexless.

2. MF. Age: 41
Still lives as a woman, with a female partner. Part-time employed. She was partly raised in institutions, because of physical abuse by her father. Two suicide attempts at 14. Spent some time in several psychiatric clinics (anxiety, aggression, bipolar disorder, psychosis) and in jail.

Had, as a child, problematic contacts with male peers. No aversion against penis. First cross dressing at 14. Wish for SRS at 16. Bisexual.

Diagnostic phase took 2 months. Assessment was done by a general practitioner. Real life test took 8 months. Doubts developed 5-6 years after SRS. Surgical complications. Does not feel like a man, women or transsexual, so all the trouble of the SRS procedure was of no use.

3. MF. Age: 43
Had returned to the male role for a while, but lives as woman again. Not employed. Physically disabled. Physical and sexual abuse in the family of origin. Mother disabled. Financial problems. First cross gender feelings at 8. Cross gender play and playmate preferences. No problems with pubertal physical changes. Sexual fantasies about men, where she sometimes had the role of a man sometimes of a woman. Suicide attempt at 23. Several psychological treatments for depression, also after SRS. Related to physical abuse by partner.

Diagnostic phase 1 year. Real life test two years. Surgical complications and doubts during treatment. She did not express her doubts, because of pressure by partner to continue.

4. MF. Age: 66
Lives in the male role again. Lives alone. Has no contact with ex-wife and children. Is retired. Financial, but no serious relational or other problems in family of origin.

First cross gender feelings at 12. No aversion against typical male clothing or physical male characteristics. No cross dressing. First cross dressing at 49. Wish for SRS at 49. Sexually oriented towards women. Attempts to have sex after SRS with men were not successful because vaginal opening had closed.

Diagnostic phase took 6 months. Real life test one year. First doubts because of the hormonal treatment and surgical complications. Regrets about treatment because of social isolation and loss of his family. Contacts with family of origin better after second role reversal. Quality of life improved after return to male role. Regrets SRS because of loss family.

5. MF. Age: 68
Lives a double life on request of his family: socially he lives as a man and at home as a woman. Only his wife and eldest child know he has been treated.

No serious relational or other problems in family of origin. No clear memory of first cross gender feelings; vague memory about his fourth year. First cross dressing at 8. Aversion against male physical characteristics before 12, this became worse after puberty. Wish for SRS at 23. Sexually attracted to women, but wanted to have children as a woman. Has always been unsatisfied with his sex life.

Since 20 several times psychotherapeutic and psychiatric treatment because of his wish to be a woman. Suicidal thoughts, but no attempts.

Diagnostic phase took 8 years. Operation 5 years after start hormone treatment. Many doubts about treatment, because of social consequences. No doubts about his cross-gender feelings.

6. MF. Age: 35
Lives on her own, as a woman. No job. Lived from early on with foster parents, at 13 in institution, because of death foster father and bad health foster mother. Before 13 no cross gender feelings and behavior and no aversion against body. First cross gender feelings and cross dressing around 13. Cross dressing accompanied by sexual arousal. Wish for SRS at 15. Treated once by psychiatrist for transsexual feelings. Bisexual feelings, but sexual contacts with men. After treatment difficulties in finding sexual partner.

Diagnostic phase 1 year. Real life test 4 years. Surgical complications and disappointing results and social isolation. Because of that regrets about her decision. She lived in the male role again for 3 years, but switched back to the female role, because was not able to live as a man.

7. MF. Age: 51
Lives as a man; a part of the week alone, the other part with his child. Employed.

In family of origin mother was dominating and she despised men. First vague cross gender feelings around 7, but no cross gender behavior. First cross dressing during adolescence. Around 30 in therapy because of depressed mood. Wish for SRS at 38. Felt asexual. If anything he was attracted to women.

Diagnostic phase 18 months. Before hormone treatment conflicts with psychologist. Real life test took 18 months. Complications as a result of hormone treatment. Testicles were removed. After the operation an indifference towards SRS developed and he never had a vaginoplasty. Returned into the male role, because it was socially easier to live as a man. Thinks he is not a real transsexual.

8. MF. Age: 45
Lives as a man again. No contact with ex-wife, only with one of his two sons. Unemployed. Worked before SR as truck driver. Raised in stable family. In childhood no identification with the other sex, neither cross gender behavior. Cross dressing started at 16 and had always been associated with sexual arousal. First cross gender feelings at 17. First wish for SRS at 30. He tried once to mutilate his penis at 32. Applied to hospital for SRS in stressful period: divorce and death of father. Diagnostic phase took 3 months and the reasonable successful real life test one and a half year. The urge to live as a woman suddenly vanished 6 months after the sex operation. Feels relieved after return to male life. Feels as a man again.

He did not express slight doubts during SR. Misses his penis, has nevertheless no regret of SRS. Had been treated before SR for alcohol abuse.

9. MF. Age: 46
Lives permanently as man with a female partner. Lost contact with ex-wife and children.

Underwent recently a mastectomy. Affectionately neglected by mother, no support by loving father. Lonely as child. Many psychological crises in later life. Some secret cross dressing with mothers' clothes between age 6 and 8; further never cross dressed. First cross gender feelings at age 11. First serious wish for SRS at 42. Hoped that SRS would solve his life problems. Diagnostic phase took 3 months, the real life test around 2 years. Social transformation from the start problematic. No acceptation. Felt burden by loss of contact with his family. Returned to male gender role two and a half year after the sex operation. Still abominates his male body, but wishes a reconstruction of his penis. Did not explicitly express hesitations about the SRS during the process. Regrets the SRS. Feels constantly depressed by existential problems. Gets medical en psychological treatment.

10. FM. Age: 32
Lives stable and permanently as woman with a male partner. Removed silicone testicles and underwent breast augmentation. Changed again her legal status. Broken contact with her own two children has been re-established. Unemployed.

Tomboyish in childhood. Contact with parents detached. First cross feelings at 4 year. Fantasized about having a penis. Problems during puberty with acceptation of her own female body and her bisexual feelings, especially the feelings towards women. Gave birth to her children at age 18 and 21. First wish for SRS at 21, first cross dressing at 22. Applied for SRS at 23. The diagnostic phase took several months, the real life test around one year. Some time after the mastectomy significant doubts raised about the correctness of the SR process. She felt an inner resistance against the male gender role. Being a man, she finally was able to accept her female side. After long deliberation she changed her gender role again. She regrets the physical consequences of the SRS process. She does not regret the fact that she followed this road to gain more insight into herself.