Sex reassignment-- most specifically
surgical procedures performed on healthy genitals-- has historically,
at least since the 1950s, been viewed as a heroic medical procedure
which is justifiable only if it alleviates the dramatic suffering of
transsexuals reported by Benjamin (1966), Stoller (1968), Green &
Money (1969), and others. In this decade, the assumptions that
underlie such reasoning have come into question, resulting in an
emerging sentiment that individuals should be allowed to do or have
done to their bodies whatever they wish. In large and ever increasing
numbers, transsexuals are not going to gender programs for sex
reassignment, but are serving as their own case managers, calling
their own shots, deciding what procedures to undergo and when, and
how much counseling, if any, they will have. Little is known about
what happens to individuals who follow such a course. What are their
outcomes? Is there a high proportion of "transsexual regrets?" Of
suicides? Are they miserable, or contented and well-adjusted, or
somewhere in between? No one really knows, as there have until now
been few outcome studies on such populations. A notable exception is
a questionnaire done by Janis Walworth and presented at the First
International Congress on Sex and Gender Issues in 1995 (Walworth,
1997). More is known about transsexuals who follow the often-strict
protocols of formal gender programs. Beginning with Benjamin in 1966,
there have been any number of outcome studies published by members of
gender programs
(Table 1).
Typically, transsexuals are followed for some years post-surgically, and interviewed periodically. Despite well-publicized problems with follow-up, and despite the methodologically flawed and apparently fraudulent 1979 study by Meyer and Reter, these follow-up studies tend to show a preponderance of "satisfactory" outcomes. Results are hardly unequivocal, but are sufficiently robust to indicate that surgery can be of benefit to the majority of transsexuals who go through clinical programs and are later available for follow-up.
It is important to study non-clinical populations for a number of
reasons. First, because they do not have to pass entrance criteria or
pay large fees, transsexuals in this group are probably more diverse
than those in select clinical groups. Second, individuals outside
clinical settings avoid much of the medicalization inherent in gender
programs, and so can provide a measure of the effectiveness of such
programs. But most importantly, it is important to collect such
evidence in order to show the benefits of sex reassignment surgery,
as there are those who would very much like to see it ended. There is
considerable evidence (cf Kessler & McKenna, 1978, Bolin, 1988)
that much of the existing literature is less than reliable because of
the power dynamics inherent in settings in which clinicians have
gatekeeping power over transsexuals; this is well known to result in
transsexuals being less than honest with their caregivers. I consider
this a significant enough problem that I am skeptical of any
clinically-based study which relies on self-reports of transsexuals,
or in which transsexuals might be motivated to conform to the
clinicians' expectations. Why have there been few studies outside of
clinical settings? Is it because non-clinical populations of
transsexuals are unavailable? I think not. Anthropologist Anne Bolin
readily obtained access to a support group in the mid-West, and other
researchers like George Brown (Brooks & Brown, 1994) who have
approached the transgender community have readily found subjects.
Perhaps there are no such follow-up studies because clinicians have
ready access to their patients, and have not looked elsewhere, and
non-clinicians have not had funding sufficient to perform such
studies. Or maybe it's just that nobody has bothered to look. Despite
their rarity, studies outside the clinical setting have been most
instructive. For example, Kessler & McKenna's ethnomethodological
work in the seventies (Kessler & McKenna, 1978), and Bolin's
observational study in the 1980s (Bolin, 1988) have played a major
role in the reframing of transsexualism and the rise of the
transgender paradigm, even if they have been virtually overlooked by
clinicians. I believe that the most productive work in the next
decades will be done not with transsexuals in special settings like
gender clinics, but in the real world, where transsexuals live their
lives. And as new findings emerge, I believe that many of the
supposed shortcomings of transsexuals documented in the early
literature will be shown to be artifacts of the research methodology.
In 1991, I formed a transgender support group in a major city in the
Southeastern United States. The group was "open," which means that
anyone with a gender issue, any family member or partner, or anyone
with a legitimate interest in gender issues could attend. There was
already a transsexual support group in the city, but I was
dissatisfied with its rigid expectations for its members. Whatever
their life situations, members were expected to go on hormones,
transition gender roles, have genital surgery, and disappear into the
woodwork to live "normal lives" as nontranssexual-- that is "cured"--
men and women. Individuals who were unwilling or unable to follow
such a course were pronounced "nontranssexual" and excluded from the
group either formally, via a letter, or by peer pressure. This
created a self-fulfilling situation, in which "true transsexuals"
were those in the group; those who were not in the group were "not
transsexuals." The new group had no such expectations. Members were
encouraged to explore their options via therapy and find a course
that worked best for them. Peers were supportive of members'
decisions, whether they led to sex reassignment, full-time
crossliving without expectation of surgery, acceptance of cross-
dressing, or, in one instance, moving to another state in search of a
religious "cure." The group nonetheless attracted a large percentage
of transsexual persons, with perhaps 60 individuals transitioning
gender roles and having genital surgery in a five- year period.
Members of the group came from many walks of life. However, the
group, diverse as it is, does not accurately represent the
transgender community. Its members tend to be white and of the middle
class. The city's large population of transpersons of color do not
tend to attend the meetings, nor do many of the Caucasian
transindividuals who are very evident in the city's bars. Also,
female-to-male persons are under-represented. In my position as a
member of the group, I have been in the position of
participant-observer, much as was Anne Bolin in her field study,
which is reported in her book In Search of Eve (Bolin, 1988). The
major advantage of this perspective is that it is divorced from the
treatment system and the biases inherent therein. Although I educated
group members about the Standards of Care, various medical
technologies, and strategies for successful transition, at no time
did I serve as a caregiver. Consequently, communication was open and
easy, and there was no incentive for group members to please me. In
fact, believe me, when group members are not happy with me, they do
not hesitate to let me know it. Before I present five cases, I would
like to say that in some ways, my findings are rather different from
previous studies. For instance, despite the problem with lack of
follow- up reported in most clinical studies, I am in touch with, or
could easily get in touch with, practically everyone who has
transitioned through the group. Whether or not they continue to
attend meetings, group members are part of a network of friends,
lovers, and housemates, deriving support from, and giving support to,
each other. I am part of this network. It's significant that in
clinical studies, the problem with lack of follow-up has often been
attributed to the less than reliable nature of the subjects. Although
it is possible that I had a more honest group of subjects, it seems
apparent that previous problems with follow-up had more to do with
the quality of the relationship between clinicians and subjects than
with the characteristics of the subjects themselves. And not only
that, if subjects of previous studies were pronounced "cured" and
expected to disappear into the woodwork-- and they were-- it is
hardly surprising that many of them effectively did so. My study is
still in process, but my best guess at present is that my results
will show that most group members did very well. In fact, I will be
surprised if they did not do as well or better than subjects from
gender programs with their manifold requirements-- which calls into
question the necessity for gatekeeping for the average transsexual. I
will present today five case studies of group members. I have made no
attempt to present only successful cases, although I have made sure I
have at least one outstanding example of male- to-female transition,
and one outstanding example of female-to- male transition. The
individual circumstances of all subjects have been disguised.
Case #1: Michelle
Mike T. was a psychiatrist and a Methodist minister in his late
thirties, married, with three teenage children, one of whom was
autistic. He had been struggling with his gender issues all his life.
He had been sneaking his wife's birth control pills when he suddenly
realized that he had to deal rationally with his issue. He contacted
a nationally renowned therapist and was referred to AEGIS, a national
clearinghouse for transsexual and transgender issues-- which,
incidentally, I founded. AEGIS referred him to the support group. He
began attending meetings, and exploring the possibility of transition
in therapy. He had been in counseling for many years, but had not
until then broached the issue of his gender dysphoria with his
therapists. Mike transitioned fairly rapidly, although not recklessly
so. Predictably, his life began to fall apart. His marriage
dissolved, the partners in his therapy practice asked him to leave,
and his church began proceedings to remove his ordination. Also, the
breakup of the family home required that his autistic son be placed
in a very expensive group home. From the ruins of Mike's life,
Michelle emerged. Michelle slowly began to rebuild her devastated
therapy practice, came to terms with her family members (who
eventually became very supportive), and successfully campaigned to
keep her ordination. Michelle became a leader of the support group
until she decided to pull out because she saw an ethical conflict
between being a group member and being the therapist of some of the
group's members. Throughout her transition, Michelle acted with good
sense and grace. Keeping her ordination required a great deal of
politicking and a great deal of courage. She went to Sunday services
at various churches of her denomination; had a reception at her house
for her supporters at the church; worked with a group appointed by
the church to study the "problem" she presented, answering with good
nature their often embarrassing questions; and cemented old
relationships and formed new ones over lunch or dinner. She dealt
well with local and national media coverage caused by her struggle
with the church. Within three years of beginning transition,
Michelle's church had voted to sustain her ordination, her practice
had improved dramatically, and her relationships with her family
members was natural and without strain. She is now over a year
post-surgical, with no regrets, and her life has begun to assume
normalcy. The challenges Michelle faced would have been overwhelming
for anyone, transsexual or nontrassexual, but her maturity and
strength of character caused her to persevere against long odds.
Case # 2: Dale
Donna, a systems analyst who worked for a large computer company, was
in her mid-twenties. Like Michelle, she had been struggling with a
gender issue all her life. She had decided to go to a gym and attempt
to obtain steroids, but before she actually did so, she saw a
television program which featured members of the support group, and
contacted the group. Donna was masculine in appearance, and typically
wore men's clothing. She had been slowly transitioning at work,
cutting her hair short, getting rid of her skirts, and taking on the
gender- ambivalent name of Dale. Dale's approach to transition was
very structured, just like his programming techniques. He learned
what he could from the group, and thereafter rarely attended
meetings, although he remains in touch with group members, and dated
one group member for the better part of a year. During this time, he
had top surgery and obtained counseling in preparation of beginning
hormonal therapy. He was cautious about beginning hormones, wanting
to work though his feelings about them before starting, for he
suspected that their effect would be rapid and dramatic. Hormones
indeed were rapid and dramatic, causing changes in Dale's voice and
appearance. Interestingly, despite these changes, he never discussed
his situation with his supervisor or other employees, one of whom was
a lesbian who kept feeling him out. His supervisor collaborated by
never bringing up the issue. Gradually, Dale's co-workers and
customers began using masculine pronouns. Dale reported that things
were occasionally awkward, but that he did not feel that he was in
danger of losing his job. After he had fully transitioned, Dale left
his company to form his own consulting firm. He opted out of the rat
race by moving to a country location near the city and chose to work
only part-time rather than working to build his business to its
maximum potential. Most of Dale's family members were aware of his
change to the male role, and there was some resistance from an uncle.
Dale, who had always been very fond of his elderly and frail
grandmother, and whom he visited frequently, chose not to burden her
with the knowledge of his transition, and stopped visiting and
calling. He writes weekly. He states that he misses his grandmother a
great deal and wishes that he could see her, but stands by his
decision not to see her. Several years after his transition and top
surgery, he has no regrets.
Case # 3: Imelda
Bob, a married man in his early sixties, was an engineer employed by
an aerospace firm. He had no history of crossdressing or gender
dysphoria, but discovered one day that wearing bracelets put him "in
touch with his inner feelings," which he had until then denied. This
led to crossdressing, which in turn led to his joining a support
group for heterosexual crossdressers. There, he met members of the
open group and joined. He became active in the group and served as an
officer for a year. After several years, Bob, now Imelda, stopped
coming to meetings. Imelda still occasionally attends gender
community gatherings, but is distant with other group members. Bob
went through a period at work in which he dressed androgynously.
Profoundly bald, he began wearing a short woman's wig and
gender-neutral clothing. Slowly, Imelda emerged. She broached the
issue of her gender transition with her employer-- an event of major
importance, since her work required that she keep her security
clearance. She did a great deal of research into the best way to
handle her transition at work, and indeed, was able to keep her
clearance and her job, although things were quite awkward at work for
several years, and may still be so. Imelda was soon divorced. She
dated several group members; in fact, one group member (Case #4)
dropped his femme persona and came off hormones in order to be her
boyfriend. She pressured him into it, insisting that he "be the boy."
Imelda was seeing an endocrinologist who had her on a very large dose
of estrogens. On a flight back to the US from South Africa, she
suffered a mild heart attack, and had to come off hormones herself.
Karma, some group members called it. Eventually, her physician placed
her on a medication which shut down her production of male hormones;
however, this medication was very expensive and rapidly cut into
Imelda's surgery fund. She looked into having orchidectomy
(castration), but its expense was such that she also began looking
into having sex reassignment surgery right away. Other group members
did not think this was a good idea, and told her that considering her
lack of time in real-life test it would be better if she waited. In
fact, group members had urged her all along to go very slowly;
several were especially worried because her gender dysphoria was of
recent origin. This is probably the cause of her later distancing
herself from group members. Imelda scheduled and underwent surgery,
and had large breast implants at the same time. She immediately
regretted the decision to have SRS, as she missed her penis and
testicles, and even had a ceremony to say goodbye to her "little
buddies." She viewed dilation as a great chore, telling group members
that it caused her great distress. She confessed to her boyfriend
that she was considering transitioning back to her Bob persona, and
went so far as to appear in a short wig and a man's suit at the
group's Christmas party. She experienced anxiety at appearing in
public, becoming somewhat obsessed with passing-- something which
other group members considered should have ceased to be an issue long
before surgery. It has been several years since Imelda's surgery. She
continues to work, and continues to present as a woman. She pops in
and out of gender community events, rarely being there on time, and
rarely staying until they are over. The best way to describe the
effect she has on others is that one member said that when she enters
a room, she feels as if the temperature had suddenly dropped ten
degrees. Imelda saw several therapists before and during her
transition, attending both individual and group counseling sessions.
She sometimes spoke in a derogatory fashion about therapists, but
this seemed to have more to do with her inability to manipulate them
than with the therapists' actual characteristics. In fact, Imelda was
very controlling in a number of ways: she talked her in-transition
lover into becoming a "boy" for her, she managed to obtain the
necessary letters for surgery despite only a short period in
real-life test, and she almost torpedoed an appearance by a noted
transgender author set up by her boyfriend when she unilaterally
decided that the event was likely to lose money and took it upon
herself to begin calling the financial sponsors of the event, urging
them to bail out. Does Imelda have regrets about transition and/or
surgery? I have not yet conducted a structured interview with her,
but there is little doubt in my mind that she does.
Case #4: Mandy
Bob, the manager of an auto parts store, had a lifelong gender issue.
He came to the group, attending for two years before deciding to
begin hormones. Six months later, Mandy, as Bob was called in the
group, was off hormones, having been pressured by her "girlfriend"
Imelda (Case #3) to "be the boy" in the relationship. Group members
urged her to live for herself and not Imelda; group members pointed
out that post-transition life would be that much more difficult if
she were not sufficiently feminized by hormones. Six months later,
having broken up with Imelda, Mandy was back on hormones. Bob got
into a spot of trouble at work because of having a rainbow flag on
his car. He took the flag off, but was dressing in an increasingly
feminine fashion. He was tolerated for a time, but was eventually
fired. He immediately entered transition. Mandy had been seeing an
electrologist who other group members considered ineffective; in
fact, she spent several thousand dollars with no appreciable
diminishing of her very dark beard. At the time of transition, she
had been on hormones for only a few months, and had a noticeable
beard shadow. Also, Mandy's hair line, her facial features, and her
stature and body build made passing difficult. Group members pointed
out to her that transition-- and specifically, finding work-- might
prove difficult. Indeed, Mandy has had ongoing difficulty with
employment, and has been unable to afford much electrolysis or
plastic surgery to feminize her appearance. She is quite obviously a
transsexual woman, and while she is proud of being transsexual, the
fact is that her readability leads to a very different quality of
life for her than for members of the group who are more passable.
Although she searched extensively, Mandy was able to find only one
job-- cooking in a restaurant. She was incensed that she was not
allowed to wait tables, for the restaurant was owned by a transsexual
woman who "should have understood." What the owner probably
understood was that a food server with Mandy's problematic appearance
would cost her business. Mandy resigned after several months, and
worked doing telephone sales for several months. When that job proved
financially unproductive, she decided to go to school to learn how to
apply artificial nails. Group members told her that her city is
wall-to-wall with nail parlors, and that nails sell for as little as
fifteen dollars per set; they wondered how she could possibly make a
living doing nails. Mandy went to school anyway. She experienced
considerable discrimination and harassment at school. Afterwards, she
was turned down for employment in many nail parlors, and finally
found work in a small parlor in the suburbs; however, her earnings
were very small. Mandy was still in the group, and was in fact, an
officer for a year. Group members suggested that she might consider
taking a roommate and finding a less expensive car in order to lower
her living expenses, but she did not do so. Eventually, she quit her
job at the nail parlor. She finally found a job delivering bottled
water, but was fired when a new manager came on board and saw her.
She found a job at another delivery company, where she makes minimum
wage and some tips. The business is gay-owned, and she was incensed
when the owners came to her and told her that they were convinced
that Mandy's appearance was cutting into their sales and that they
were going to limit Mandy's delivery area to the gay-friendly parts
of town. This cut into Mandy's income. Throughout this period, Mandy
was the Treasurer for a gender conference which is held in a
Midwestern city. The Board of the conference discovered--
unfortunately, just as the conference was gearing up-- that she had
embezzled approximately seven thousand dollars, the amount,
coincidentally, there was in the bank account. The Board agreed not
to press charges only if Mandy would make regular payments in
restitution. Mandy has been paying regularly for two years now. Mandy
has not had surgery, but is slowly building up a fund to allow her to
do so; she is able to do so only by working two low-paying jobs. On
the eve of this presentation, she told me that her surgery date had
been set. Several years into transition, Mandy has been embittered
and politicized by her work experiences. She no longer comes to group
meetings, although she is in contact with group members and
socializes with them. She is angry at the gay community for not being
supportive enough, and has written several letters to the gay press
on the subject. Certainly, her situation is difficult. Well-educated,
intelligent, and personable, she is nonetheless unable to get a
good-paying job, and finds it difficult to keep even menial jobs
because of discrimination. She gets catcalls and jeers almost every
day of her life. Even people who have no difficulty with Mandy's
transsexualism feel uncomfortable around such an angry person.
Assuredly, Mandy could have handled her transition in a better way,
but the fact is that her physical characteristics-- her detectability
as transsexual-- cause her to be discriminated against. She does not
regret her transition, but is understandably unhappy about her
current low level of income and indignant about the treatment she
receives from others.
Case #5: Jaxa
Jaxa lives in a small Georgia town about an hour's drive from
Atlanta. At about age 13, she told her family that from then on, she
was going to be a girl-- and she was. She attended high school as a
girl. Although almost everyone in her town "knew," she was able to
live fairly comfortably as a woman. When she was 23, Jaxa happened
upon a gay magazine with a help column. When she wrote, explaining
her situation, her column was printed, and she was referred to AEGIS.
I met with Jaxa and told her about the requirements for transition.
She presented as typically female. She was practically unreadable,
and quite attractive. Jaxa had never been on hormones. Although Jaxa
attended only a couple of group meetings, she remained and remains in
touch peripherally. Jaxa attended counseling sessions long enough to
get a letter for hormones. Hormones made little difference in her
appearance, serving only to round out her features a little. About
three years after she approached me, Jaxa had SRS. She was such a hit
with her surgeon that she appeared with him and her boyfriend in a
short feature on The Playboy Channel. It is now about three years
since her surgery. Jaxa works as a waitress in a sports bar. She has
no regrets. I will present further results of this study this
September in Vancouver at the Meeting of the Harry Benjamin Gender
Dysphoria Association.
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Berger, J.C., et al. (1990). Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Distributed by AEGIS, P.O. Box 33724, Decatur, GA 30033.
Bolin, A. (1988). In search of Eve: Transsexual rites of passage. South Hadley, MA: Bergin & Garvey Publishers, Inc.
Brooks, G., & Brown, G. (1994). International survey of 851 transgendered men: The Boulton and Park Experience. Paper presented at the Sixth Annual Texas "T" Party, San Antonio, TX, 26 February, 1994.
Green, R., & Money, J. (Eds.). (1969). Transsexualism and sex reassignment. Baltimore: The Johns Hopkins University Press.
Kessler, S.J., & McKenna, W. (1978). Gender: An ethnomethodological approach. New York: John Wiley & Sons. Reprinted in 1985 by The University of Chicago Press.
Meyer, J.K., & Reter, D. (1979). Sex reassignment: Follow-up. Archives of General Psychiatry, 36(9), 1010-1015.
Ogas, O. (1994, 9 March). Spare parts: New information reignites a controversy surrounding the Hopkins gender identity clinic. City Paper (Baltimore), 18(10), cover, 10- 15.
Stoller, R.J. (1968). Sex and gender: On the development of masculinity and femininity, Vol. 1. New York: Science House.
Walworth, J. (1997). Sex reassignment surgery in
male-to-female transsexuals: Client satisfaction in relation to
selection criteria. In B. Bullough, V. Bullough, & J. Elias
(Eds.), Gender blending, pp. 352-369. Amherst, NY: Prometheus
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AEGIS
P.O. Box 33724
Decatur, GA 30033-0724
Hotline; (770) 939-2128
Business; 770) 939-0244
Information & Referrals (770) 939-1770
aegis@gender.org