George R. Brown, M.D.
The term “gender dysphoria” (1) describes a heterogeneous group of individuals who express varying degrees of dissatisfaction with their anatomic gender (hence “gender dysphoria”), and the desire to possess the secondary sexual characteristics of the opposite sex. Only a minority of these patients can be considered on the extreme end of a spectrum of subjective dissatisfaction wit h assigned anatom y and societally sanctioned gender role (i.e., “transsex ual”). The number of such patients presenting to psychiatric clinics has greatly increased subsequent to the 1966 publ ication of Harry Benja mi n ‘s seminal work, The Transsexual Phenomenon (2), and extensive media coverage of i ndivid ual cases, e.g., Ch ristine jorgensen, Jan Morris, and Renee Richards, MD.
While the term “transsexualism” was in troduced in 1949 (3), its use was not standardized until i ts initial appearance in DSM -III in 1980 (4). DSM –III-R (5) contains significa nt revisions i n the clinical definition of tra nssexualism and includes a new diagnostic category for patients who are gender dysphoric bu t do not meet the restricti ve criteria for transsexualism: gender identity disorder of adolescence or adulthood, nontranssexual type. It is apparen t from this evolu tion of nosologic though t that not all patients who pre ent with gender dysphoria and the ch ief complai nt, “I want a sex change operation,” are transsexual. Wh ile the incidence of male-to-female transsexual ism is conserva tivel y estimated at 1:37,000 anatomic males (6), the prevalence of severe gender dysphoric conditions is believed to be at least ten times h igher (7). This is based on the diagnoses of patients who are seen at approximately 40 specialized gender identity clin ics in North A merica (Table I ).
The probability of obtaining sex reassignment surgery (SRS), i.e. surgica l alteration of existing genital structures to anatomically approximate those of the other sex, morphologically and functionally, through an established gender clinic ranges between 15% and 27%, depending on age, sex, diagnoses, and other factors (8). It is estimated that over 11,000 SRS procedu res have been performed i n the U.S. alone (9), with anot her 60,000 U.S. citizens considering themsel ves to be val id candidates for such procedu res (10). Clin ical psych iatrists are li kely to evaluate one or more patients i n their practices for whom gender identity disorders are the primary diagnostic consideration, even in such “unli kely” environments as the military service (1 1).
Differential Diagnosis of Gender Dysphoria
Primary and Secondary Transsexualism
Transvestism with depression or regression
Schizophrenia with gender identity disturbance
Effeminate homosexuality with adjustment disorder
Career female impersonators
Borderline Personality Disorder with severe gender identity issues
Body Dysmorphic Disorder
Gender Identity Disorder, nontra nssexual type
Atypical Gender Identity Disorder Ambiguous gender identity adaptation
The Harry Benjami n International Gender Dysphoria Association (HBIGDA) was founded in 1979 by a group of psychiatrists, surgeons, psycholo gists, endocrinologists, and social workers who are actively i nvol ved i n gender identity research and the care of gender dysphoric patients. This author is the on ly psychiatric resident member of the organ ization and has had the opportu nity to collaborate with ma n y of the founding mem bers. The HBIGDA has recogni zed the n umerous bioethical and medicolegal issues surround ing the care of gender dysphoric persons, and pioneered formal Standards of Care in the late l 970’s (12). These original standards have since been revised and were made available to the professional community i n 1985 ( I 0).
My experience at the Case Western Reserve Gender Iden ti ty Clinic and clin ical evaluation of 17 severely gender dysphoric patients in four cities (Rochester, Clevela nd, Cincinnati, and Dayton) over the previous five yea rs prompted an examination of the bioethical issues encountered in the manage ment of such patients. All patients evaluated were anatomic males with the expressed wish for SRS. Three patien ts had already u ndergone SRS, one was accepted for SRS and had received cross-gender hormonal treatments for over a year, five others had self-administered cross-gender hormones obtained illicitly, and the remaining eight were at various stages of the evaluation process.
The discussion that follows is not to serve as a sterile debate of issues, but rather as an attem pt to familiarize the reader with the difficult ethical concerns inherent in caring for individuals who desperately seek reassignment.
THE PHYSICIAN’S DILEMMA
The availability of sex reassignment surgery as an intervention in the overall management of transsexualism raises a number of bioethical issues for physicians. The term “bioethical ,” albeit accurate, does not begin to describe the intense reactions experienced by those of us who are asked to, or choose to, ponder the question of gender transm utation. This is evidenced i n published statements by respected clinicia ns such as Lawrence Kubie:
“This passing fad for what is miscalled ‘transsexualism ‘ has led to the most tragic betrayal of human expectation in which medicine and modern endocrinology and surgery have been engaged (13).”
What the late Dr. Kubie referred to as a “passing fad” has anything but passed us by. Gender dysphoric patients continue to present to gender identity clinics and private practitioners a critical need for psychiatric care. These patients engender a sense of desperateness and urgency unparalleled in most other areas of psych iatry. Their lives become a “frantic preoccupation ” (14) with obtaining cross-gender hormones and SRS, often to the exclusion of progressing through school, building relationships, or maintaining employ ment.
Physician response may be to ally with the patient in his all-encom passing quest for somatic treatment, leading to prescription of hormones and referral for SRS. Alternatively, physicians may be extremely reticent to entertain such treatment requests, erecting the defensive facades of “do no harm” and “never deliberately remove a healthy organ.” This tack may be represented in Kava naugh and Volkan’s pejorative description of SRS as “a new type of psychosurgery” (15).
Physicians are faced with a complex dilemma that revolves around two central questions: What constitutes suffering in the gender dysphoric patient, and what are the ethically and morally viable interventions available to rel ieve suffering in these patients? The Oath of Hippocrates (16) reminds us that the relief of suffering is the quintessential task of all of medicine. The gender dysphoric patient relates his subjective experience of suffering very clearly, but what the physician may do to relieve it is unclear. J. Cassell, an internist, warns us:
The most wel l-intentioned and best-trained physicians may cause suffering inadvertently in the course of treating disease and may fail to relieve suffering when that might otherwise be possible (17).
Psychoanalytic theory emphasizes that one’s “highly prized sexual organs” (18) are cathected with a great amount of libidinal energy. A male who pleads with us to castrate him and amputate his penis may arouse, on an unconscious level, significant castration anxiety. Lothstein described such anxiety in a male anesthesiologist who nearly suffocated a male-to-female transsexual patient during SRS (19). The capacity to fully empathize with such a patient may be rarely, if ever, found in non-gender dysphoric individuals even if they are sympathetic to the plight of the transsexual. Significant countertransference issues are certainly evident in comments published by two surgeons who have performed SRS:
Our big problem is to differentiate the dissatisfied old homosexuals who just want a new thrill from the true transsexuals.
Some of the people who apply for this kind of operation are just flaming faggots. After you have talked to a few of them there is no problem in distinguishing among the transvestite, homosexual, and transsexual (20).
The inability to fully empathize is a potential obstacle to objective medical care and unbiased, meaningful outcome studies in the field of gender dysphoria . This, in turn, contributes to the difficulty in addressing the ethical questions.
Psychiatrists have examined the legitimacy of recommending a radical surgical intervention for a disorder considered, but not established, to be primarily psychiatric in origin (21). What interventions clash with one’s identity as a psychiatrist? Where does one turn for guidance when faced with actual clinical situations with desperate, gender dysphoric individuals?
The decision-making process may be enlightened by a review of the Hippocratic Oath:
I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous ( 16).
In this instance the Oath appears to support an approach to gender dysphoria that may ethically include SRS if it is considered by the practitioner and patient alike to be of potential benefit. Conversely, the same Oath excerpt may be used to condemn SRS as harmful, mutilative, and deleterious. The scientific litera ture may serve as an additional source of information to address the ethics of an intervention. For example, if a surgical intervention is shown to be useless or harmful in replicated, controlled studies, it is likely that physicians would consider continued use of such a procedure u nethical. In spite of the fact that SRS has been performed for 24 years in the United States, it is still unknown whether it is the most effective form of treatment for transsexualism (22). Clinical decisions m ust be made in the absence of definitive, prospective, long-term studies of the effectiveness of SRS compared to nonsurgical treatment modalities (23). Decisions must also be made with the awareness that the psychiatrist shares the “moral responsibility for that decision (i.e., whether or not to refer for SRS) with the surgeon who accepts that recommendation “(10). The determination by some physicians to consider SRS an ethical thera peutic adjunct is largely a matter of personally witnessing individuals as they u ndergo the painful process of gender reorientation, which may include SRS and hormonal treatments. Numerous authors have reached the conclusion that SRS can contribute to the relief of suffering, enable better psychosocial adjustment, and impart a sense of well-being to these distressed individuals (9,22,24,25). Others have disputed these claims, noting that positive outcome studies are seriously flawed by researcher bias and the lack of control groups (23,26). A comprehensive review of the l iterature pertaining to gender dyspho ria since 1980 conducted by the author (265 articles by 174 different first authors) revealed that quantitativel y more articles are supportive of SRS for carefully selected patients. This, of course, does not necessarily represent consensus, and may only demonstrate that those who support SRS are more prolific.
Lacking definitive studies, anecdotes and personal experiences supportive of SRS as a viable treatment modality are bolstered by the pu bl i sh ed consensus statement of the HBI GDA that “hormona l and surgical sex reassign ment has been demonstrated to be a rehabilitative, or habilitative , experience for prop erly selected adult patients” (10). As noted, all experts in th is field are not in agreement that this has been adequately demonstrated.
While we can agree that man’s dignity transcends his biological condition, the radical alteration of a patient’s “natural” physical condition because he requests it, will continue to be an ethical issue as we search for ways to enable gender dysphoric patients to reduce the dissonance between their anatomy and their sense of self.
SELECTION OF PATIENTS
If one concurs with the HBIGDA in the opinion that SRS can, in fact, contribute to the relief of suffering and enable better psychosocial adjustment, another ethical dilem ma immediately becomes apparen t: Wh ich gender dys phoric patients should be approved for surgery? In our calculated attempts to relieve suffering, the m isapplication of irreversible genital surgery is associated with disastrous conseq uences including depression , psychosis, suicide and a total loss of dignity and self-esteem (27-30). Wh ile SRS cannot tru ly be credited wi th “creating” a woma n out of a man (and certainly not vice versa), it can be blamed for creating an anatomically distinct third category of “other,” i.e. the post operative transsexual , who may feel even more alienated and biologica lly incongruent than before SRS (31).
As we struggle with these issues in the context of facing disturbed gender dysphoric patients who are absolutely convinced that only hormones and surgery will end their pligh t, we must keep several concepts in mind:
I . The request for SRS is the solution the patient has presented to us.
What then, is the nature of the problem in a given patient?
- . Radical surgical interven tions cannot alter an Axis II diagnosis of personality disorder, conditions diagnosed in 50-70% of applican ts for SRS (32).
- Surgery alone is not curative or rehabilitativ SRS is only one compo nent of a m ultidisci plinary approach to the rehabilitation process and should be viewed as confirmation of what the patient has already achieved with our assistance (22,33,34).
It is clear then, that for any patient referred for SRS this step should be an anticlimactic conclusion of what has already been achieved, prompting Edger ton, a prominent SRS surgeon, to consider this “sex confirmation surgery” (22).
Sadly.just as resourceful patients are able to obtain hormones illicitly, they can also obtain some forms of SRS from surgeons u naffiliated with established gender clinics in the U.S. and abroad (35). Many of these individuals have been subjected to “inferior surgical techniques and preoperative selection proce dures” with outcomes anecdotally reported as “horrifying” (36). One such patient awoke from anesthesia to find that her newly created clitoris had been placed inferiorly to her urethra (37). Since the publication of the formal Standards of Care for the evaluation and treatment of gender dysphoric individuals ( l 0, 12), there would appear to be little room for the “chop shop” or “bargain basement” approach to SRS (34). Civil liability could be incurred by a surgeon in cases where the patient is dissatisfied with cosmetic and/or functional outcomes on the grounds that negligence occurred in preoperative evaluation. The case against the surgeon would be strengthened if the evaluation was brief and/or inconsistent with the Standards of Care, which clearly state that a minimum of two qualified mental health professionals must thoroughl y evaluate the patient longitudinally, prior to recommendations for SRS. Criminal charges could be filed as well, with prosecution based on the premeditated “act of intentionally mutilating a person’s body or injuring it so as to deprive him of a limb or any organ of the body,” i.e. mayhem (7,38).
The probability of a poor outcome, including post-operative suicide, is believed to be increased in patients who receive SRS without proper evaluation and lengthy preoperative preparation, including one to two years minim um of successful cross-gender living (9, 19,32,39,40). This is likely to be a result of operating on individuals who:
l . Impulsively request SRS after a major loss (concurrent diagnosis of complicated bereavement, adjustment disorder with depressed mood , major depression) (32).
- Have a primary Axis I diagnosis other than transsexualism . For example, transvestism with marked regression under stress (41) or other disor ders listed in Table l .
- Have a personality disorder that includes a high degree of impulsivity (borderline, histrionic, antisocial).
Hundreds of patients choose to work with established gender clinics, which num ber about forty in North America (7,10). Proced u res are offered only to those patients who complete a multistep program, which by design includes a number of obstacles. For example, patients are required to live and work full-time in the cross-gender role for a mini m u m of one or two years, engage in psychotherapy for at least a year, main tai n a responsi ble payment record with the psychotherapist , get divorced if married (SRS will not be performed on ma rried patients for legal reasons), and take cross-gender hormones for at least one year if medically tolerable (7,32). Negotiation of these obstacles may resul t in enhanced ego strength mediated by successful psychotherapy and selection of nonsu rgical alternatives, e.g. hormonal treatment alone or long-term group psychotherapy (42). If the patient is able to collaborate successfully with the gender clinic’s staff in meeting these requ irements and still desires SRS, referral is made for those who, in the opinion and judgment of the clinic staff, can profit from it by establish i ng a prod uctive, socially acceptable lifestyle (34).
The bias inherent in this judgement is i ndisputable and varies among clinics. For example, some would consider prostitution by a reassigned male to-female patient an acceptable professional outcome if the patien t is self supporting, not receiving public assista nce, and satisfied wit h this vocational choice. Others would consider this objectionable and u nacceptable and would deny referral for SRS if this was known to be the patient ‘s long-range career goal.
Patients considered “ideal” for referral (9) are those Fleming and Fein bloom have called the “psychologically healthy transsexuals ” (43). They are the patients who do not seek to destroy or condemn the “old” self, bu t rather integrate earlier experiences into the “new” transformed self. Table 2 summa rizes some of the features of patients considered acceptable as candidates for SRS i n contrast to features associated with high risk or u nacceptable applica nts (9). Most of these parameters have been derived empirically from over two decades of surgical and psych iatric experience with gender dysphoric patien ts.
In addition to the features listed in Table 2 under “poor candidates, ‘ there are some relative contraindications to offering SRS that should be considered i n the overall evaluation process:
- Mental retardation. Grossly subnormal intellectual function ing may be incompatible with i nformed consent regarding the conseq uences of SRS and its
- Past h istory of psychiatric illness such as schizoph renia, bipolar ill ness. A diagnosis of thought or affective disorder years before a request for SRS is not necessarily incom patible with good outcome (10,34).
- Poor medical condition, e.g. inabil ity to tolerate hormonal treatment, or other physical disorders that would place the patient at risk for major surgical procedu res. (Few conditions exist that would be absolute contraindications, as modern anesthesia practice enables surgery to be performed safely on most individ )
The characteristics of acceptable candidates for SRS continue to u ndergo revision as more data becomes available (40). Just as it is impossible to predict with certainty which young, first-admission manic patients will relapse in the future, it is also not possible to predict which gender dysphoric patien ts will have an overall positive or negative post-surgical adjustment. Many believe, however, that patient compliance with treatment coordinated by an established gender identity clinic and demonstrated success i n the cross-gender role for one to three years may be the most valuable selection criteria and prognosticators (9,33,34,39).
Categorization of Candidates for Sex Reassignment Surgery
- Lifelong cross-gender identification
- I nability to adapt/to live in assigned biologically congruent gender role
- Capacity to “pass” effortlessly and convincingly in society
- Not considered a fetishistic cross dresser
- First heterosexual experience, if pres ent, was in early adulthood rather than adolescence
- Some college education
- Demonstration of “stability”-holding same job for years, long-term relationships, etc.
- Willingness to accept and actively en gage in psychotherapy pre and post operatively
- Presence of adequate social and/or family support systems
- Com pletion of a program at a recog n ized gender identity clinic, including two years of successful living/worki ng in cross-gender role
- At least one year of medically super vised hormonal treatment
- Absence of any characteristics of “poor” candidates
- Therapist comfort i n referral after long-term psychotherapy relationship
- Absence of characteristics listed under “good” candidates
- Active or recen t thought disorder or affective disorder
- Exclusively fetishistic use of cross dressing
- Recent identifiable major loss precipi tati ng im pulsive request for hormones and SRS
- History of significant antisocial behav ior
- Multiple suicide gestures and at tempts, including genital self-mutilation
- Active substance dependence
- Lack of social and/or financial sup- port system
- Lack of funds to finance medical care and postoperative complications
- Delusional/magical expectations of surgery
- Circu mvention of gender identity clin ics and procedures, g. illicitl y obtain ing hormones
- Significant resista nce of therapist af ter long-term psychotherapy relation ship to refer for SRS even though ther apist has referred others
SUICIDE AND SURGERY
The dictum, “above all, do no harm” takes on a pa rticula r significa nce when any psychiatric patient comm its suicide. Ethical and moral questions become more pressing as we retrospectively exam i ne our relationshi p wi th a patien t who has suffered this outcome. What could we have done, if an yth ing, to prevent such a tragic occurence? Along with psychotic decom pensation (44), post-operative suicide is often cited as the most compelli ng reason to disallow SRS as a treatment modality (23,45). Thorough reviews of the numerous outcome reports are provided by Lothstei n (26) and Lundstrom, et al. (40). The suicide rate in post-operative transsexuals at 11 centers has been reported as 2.1 % of those who recei ved this procedure, based on follow-u p durations of 0.3 to 19 years (40). Suicide attempts may be more frequent in gender dysphoric patients who are refused SRS than in those who receive it. In Lundstrom’s study of 30 transsexuals not accepted for SRS, one committed suicide and 59% of the remai nder attempted it at least once (46). Unfortu nately, no studies addressing suicide and SRS have separated patients into groups with and without persona l ity disorders (23). For example, the incidence of suicide attempts in patients with severe borderline personality disorder is high, irrespective of gender pathology, Therefore, data obtained from a group of gender dysphoric patients heteroge neous for borderli ne personality disorder is difficult to interpret.
How long after SRS can suicide be reasona bly considered a post-operativ e complication? Ifa patient has a poor cosmetic and functional outcome, develops a severe depression in the weeks after surgery and shortly thereafter commits suicide, many clin icians would consider this temporal relationsh i p more than coincidence (19). The fact that R uth Shu maker, coauthor of a poigna nt and i nsigh tful paper on her i ntrapsychic life as a transsexual (47), comm itted suicide seven years after SRS (28) cannot be definitively attribu ted to her treatment. An alternative i nterpretation is that SRS enabled the patient to l ive u p to seven years longer than she may have otherwise.
If we are trying to “do no harm,” do we harm less by operating more, or harm more by operating less? The 2 . 1% suicide rate previously mentioned prompted Pauly to state emphatically: “I feel it is not justified to conclude that surgery carries a higher risk of suicide or attempted suicide than does refusal ” (48).
Just as wi th classic existential issues, the answers to the ethical questions concerning SRS may never be forthcoming. It would be comfortable if there were well-designed, controlled, prospecti ve studies with large n u mbers of patients to help us address these issues (23). As these are lacking, we may be left with the same eth ical and moral dilemmas with little data to fashion our clinical opinions and much confusion to fuel our own dysphoria.
Clinicians faced with the evaluation and treatmen t of gender dysphoric individuals are plagued with difficult bioethical issues. While we, as a medical commun ity, have no qualms about genital surgery for inborn biologi cal errors, e.g. ambiguous genitalia conditions and pseudohermaphroditism (49), the same detached approach has not been applied to altering the anatomy of transsexuals. Since we have found no consistent biological (hormonal, genetic, anatomic) marker or defect, the etiology is presumed to be psychogenic/developmental by default, and the appropriateness of rad ical surgical treatmen t for functional disorder is called i nto question (50). “Above all , do no harm” is to be heeded with special care by mental health professionals facing both a lack of knowledge and an abunda nce of ethical dilem mas. This could, and should , lead to the restriction of SRS to centers i n volved in a m ultiuniversity research project aimed at addressing the relevant extant clinical questions (22,32).
In spite of proclamations that nothing else holds promise for the treatment of transsexua l ism other than SRS (25), less invasive interven tions have been shown to be useful for some patients, e.g. expressive group psychotherapy (42), hormonal treatment i n conjunction with psychotherap y (51), and behavior therapy (52). Ethical dilemmas related to d enial of SRS contin u e, such as the reported increased rate of suicide attempts and withholdi ng trea tmen t consi dered by some experts to be l ife saving. Controlled, prospective studies compar ing trea tment modal ities are needed.
ls SRS then , an elective cosmetic proced u re as most insu rance carriers claim? ls it the treatment of choice for selected gender dysphoric pa tients, or a well-intentioned m utilation tantamount to mayhem? There are no general i za tions to adhere to, no conven ient “rules-of-thu mb.” Bu t there are pa tients with severe, pervasive disturbances in their sense of self who seek ou t those hea l th care professionals who are willing to confront their own ethical and moral standards i n an attempt to provide appropriate care. Unaddressed negati ve countertransference responses to gender dysphoric patients, who are often manipulative and driven, may i nterfere with clinical decision-maki n g and contribu te to the suffering these patients endure (53).
The author wishes to thank the staff of the Case Western U n iversity Gender Identity Clinic for their guidance; Leslie Lothstei n , Ph .D., Director, Department of Psychology , The Institute of Living, Hartford, Connecticut for his i ntellectual stimulation; Sandra A. Dinwoodie for technical support and preparation of the manuscript.
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