References 8: Being out helps

Gender dysphoria in children and adolescents – treatment guidelines and follow-up study

Treatment guidelines for transidentity in children and adolescents are presently under discussion. We present an overview of the various treatment modalities. Further, follow-up data on children and adolescents referred for gender-identity problems are presented. Of the 84 patients seen for the first time more than 3 years before follow-up, 37 mailed in the completed questionnaires. In addition, 33 patients agreed to answer some short follow-up questions. We assessed steps of treatment, gender role, psychopathology, and psychotherapy. We compared differences in psychopathology in patients with vs. without gender role change and in patients with intense vs. less intense psychotherapy. A total of 22 patients had completely changed gender role, and some had started hormonal treatment und sex reassignment surgery. Most patients were satisfied with the treatment results. All patients showed less psychopathology on follow-up, independent of role change or intensity of psychotherapy. In general, the patients reported little psychopathology. Our follow-up results support the present treatment approach. In patients with little psychopathology, low-frequency supportive treatment appears sufficient to obtain safe judgement on hormonal of surgical treatment.

Author/-s:       Bernd Meyenburg; Anne Kröger; Rebecca Neugebauer

Publication:     Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 2015

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Long-Term Follow-Up of Adults with Gender Identity Disorder

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Author/-s:       Ulrike Ruppin, Friedemann Pfäfflin

Publication:     Archives of Sexual Behavior, 2015

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Australian Trans Men: Development, Sexuality, and Mental Health

The aim of the study reported in this article was to gain an understanding of the experiences, developmental trajectories, and mental health status of Australian trans men. Participants were 279 trans men. The majority preferred to identify as “male”; from an early age, they had experienced their gender identity as different from that normatively expected of their natally assigned sex and had undertaken practices so as to facilitate their presentation as male in accordance with their gender identity. A majority reported a diagnosis of depression or anxiety within the last 12 months and attributed suicidal ideation and self-harm and attempted suicide to personal issues with gender identity. Going through a masculinisation process and coming out reportedly led to improved mental health. The findings highlight the need to educate mental health and health care professionals on trans issues.

Author/-s:       Andrea del pozo de Bolger; Tiffany Jones; Debra Dunstan; Amy Lykins

Publication:     Australian Psychologist, 2014

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Change in Depressive Symptoms Among Treatment-Seeking College Students Who Are Sexual Minorities

Changes in students’ depressive symptoms during the course of treatment at college counseling centers were examined by sexual orientation. In Study 1, results showed that depressive symptoms decreased similarly across sexual orientation groups during the course of treatment. In Study 2, family support did not moderate the relationship between pre- and posttreatment depressive symptoms but had a direct effect on posttreatment depressive symptoms for students questioning their sexual identity. Clinical implications are discussed.

Author/-s:       Jessica C. Effrig; Janelle K. Maloch; Andrew McAleavey; Benjamin D. Locke; Kathleen J. Bieschke

Publication:     Journal of College Counseling, 2014

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Disorders of gender identity: what to do and who should do it?

Transsexualism is not usually indicative of psychopathology. In carefully selected individuals, with multidisciplinary support, a change of social gender role and cross-sex hormone treatment greatly improves the psychological and social state. Sustained improvement merits gender reassignment surgery. The key is early referral with subsequent primary care cooperation in the treatment plan.

Author/-s:       James Barrett

Publication:     The British Journal of Psychiatry, 2014

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It’s a gendered world: The experience of parents and their transgender youth

Summary of Study: The experience of parenting transgender youth was explored by conducting individual, semi-structured interviews with nine parents of transgender youth whose children ranged in age from six to 20. The participants, all residents of Northern California, were interviewed in their homes, at Sacramento’s Gender Health Center, and over the phone using a secure and private line. Analysis of interview transcripts revealed eight key themes: Knowledge, Peer Support, Positive Reactions and Social Acceptance, How Transition Promotes Well-being, Comfort in DSM Diagnosis, Worries and Fears, Accepting Their Children and Rejection and Discrimination. The analysis also revealed two isolated, less-common themes: Siblings and Misdiagnosis. Interpretation of the findings reveals a number of factors that are critical to the enhancement and development of effective professional services for these parents and their transgender youth, as well as critical insights reflecting an urgent need for education and advocacy within communities. Study findings also promote the idea that these families, parents included, benefit from peer support and a sense of belonging to the transgender community. Findings also support the well documented, yet still commonly disputed assertion that transgender children have an increase in happiness and overall well-being when they are permitted to transition. Further findings highlight the experience and potential struggle to accept one’s transgender child, as well as the fears of both safety and social rejection that these families experience. Interpretations of the findings also included unexpected key insights into the experiences of this population. Among them, the researcher noted that in addition to the need for more professional advocacy and training, the lack of knowledgeable professionals in the field of gender studies has resulted in long commutes for services, which inadvertently communicates that there is something wrong, rare and unfavorably special about these youth and their families. Interpretation of the findings also revealed an unprecedented counter-argument to the long-standing debate over whether or not gender identity issues should be included in the DSM: five study participants reported finding the DSM diagnosis to be an immensely beneficial source of comfort and a sense of direction both for themselves and their transgender children.

Conclusion: The results of this phenomenological study provide insights into the needs and experiences of transgender children and their parents. Examination of interview transcripts enabled the researcher to describe a number of key themes that indicate an overwhelming need for public education about what it means to be transgender, and for means of fostering tolerance and acceptance for this population. These key themes also provide insights about such things as the benefits of social support and acceptance from friends and family, the positive effect of transition on a child’s well-being, and the positive effects of DSM diagnosis. The research findings highlight how education is crucial for preventing rejection and discrimination, as well as bring to light the need for sibling support and earlier, more accurate diagnosis. Lack of knowledge about transgender issues is a critical component of the research findings. This includes the pressing need for professional development among counseling, social work, school and medical professions, which must include comprehensive training regarding how to identify and treat the needs of transgender youth and their families with compassion, dignity and respect. It is the responsibility of social workers to advocate for this population and to use our voices and expertise to promote more education, better care, more inclusive policies and regulations, and an environment that upholds equality and tolerance for parents and their transgender youth.

Author/-s:       Kristin Guy

Publication:     Master thesis, Faculty of division of social work, California State University, Sacramento, 2014

Web link:'S_A_GENDERED_WORLD_Final.pdf

Psychological status as Measured by the MMPI in Japanese Clients with Gender Identity Disorder

Objective: We aimed to investigate the psychological status of gender identity disorder (GID) clients related to treatment phase and completion of real-life experience (RLE) using the Minnesota Multiphasic Personality Inventory (MMPI) retrospectively, and provide data that can be used to facilitate appropriate psychological support during treatment.

Methods: At a GID clinic, 261 male-to-female (MtF) and 138 female-to-male (FtM) clients completed the MMPI. Participants comprised three groups based on treatment status: no treatment, treatment with oral/injected hormones, or sex reassignment surgery.

Results: The mean T-score on MMPI clinical scales was higher than the average (T = 50) in GID clients (FtM = 55.3; MtF = 64.2). In addition, T-scores for MtF clients were significantly higher than those for FtM clients on 8 of the 10 clinical scales (p < 0.01). As treatment status progressed, the T-scores for 7 scales, excluding Masculinity/Femininity, Hypomania, and Social Introversion, approached those for non-GID individuals. In FtM clients who had hormonal treatment, there was increased psychological stability in those who were open about GID treatment and had completed their RLE.

Conclusion: These findings suggest that the psychological status of GID clients is more similar to non-GID individuals as treatment and RLE progress.

Author/-s:       Takaharu Hori; Hitomi Ninomiya; Tetsufumi Kanazawa; Shinya Kinoshita; Shota Ouchi; Yasuo Kawabata; Hiroshi Okada; Jun Koh; Hiroshi Yoneda

Publication:     Bulletin of the Osaka Medical College, 2014

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Reflecting Resiliency: Openness About Sexual Orientation and/or Gender Identity and Its Relationship to Well-Being and Educational Outcomes for LGBT Students

For lesbian, gay, bisexual, and transgender (LGBT) youth, coming out (i.e., disclosure of LGBT identity to others) can be a key developmental milestone, one that is associated with better psychological well-being. However, this greater visibility may come with increased risk of peer victimization. Being out, therefore, may reflect resilience and may unfold differently depending on ecological context as some spaces may be more or less supportive of LGBT youth than others. This article explores a model of risk and resilience for outness among LGBT youth, including whether it varies by community context. We tested our hypothesized model with a national dataset of 7 816 LGBT secondary school students using multi-group structural equation modeling. Consistent with our hypotheses, outness was related to higher victimization but also to higher self-esteem and lower depression. Greater victimization was related to negative academic outcomes directly and indirectly via diminished well-being. The increases in victimization associated with outness were larger for rural youth, and benefits to well-being partly compensated for their lower well-being overall. This article suggests that being out reflects resilience in the face of higher risk of victimization, in addition to promoting well-being in other ways. Nonetheless, contextual factors influence how this model operates among LGBT youth.

Author/-s:       Joseph G. Kosciw; Neal A. Palmer; Ryan M. Kull

Publication:     American Journal of Community Psychology, 2014

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Suicide Risk in the UK Trans Population and the Role of Gender Transition in Decreasing Suicidal Ideation and Suicide Attempt

Purpose: This article examines suicidal ideation and suicide attempt within the UK trans population and highlights the impact of gender dysphoria, minority stress and medical delay

Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on utilised a non-random sample (n=889), obtained via a range of UK-based support organisations and services.

Findings: The study revealed high rates of suicidal ideation (84 % lifetime prevalence) and attempted suicide (48 % lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample.

Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative.

Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that trans people who require access to hormones and surgery can be left, in many cases, unsupported for dangerously long periods of time. The article highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support.

Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across Gender Identity Services and suicide prevention.

Author/-s:       Louis Bailey; Sonja J. Ellis; Jay McNeil

Publication:     Mental Health Review Journal, 2014

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Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL.

Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire).

Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor.

Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Author/-s:       Esther Gómez-Gil; Leire Zubiaurre-Elorza; Isabel Esteva de Antonio; Antonio Guillamon; Manel Salamero

Publication:     Quality of Life Research, 2013

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Speaking from the Margins – Trans Mental Health and Wellbeing in Ireland

Conclusions – Impact of Transition on Mental Health: The key finding to emerge from this study was the significance of gender transition in improving mental health and wellbeing. Seventy-five percent of the respondents felt that their mental health had improved since transitioning. Ninety-two percent were more satisfied with their bodies and 84 % more satisfied with their lives since transitioning. Both social and physical changes of gender were shown to have a substantially positive impact on trans people’s self-esteem, happiness and quality of life. Crucial here was the importance of being able to socially transition towards their felt gender identity and having that identity recognised by others. Alongside and interacting with this was the positive role played by hormonal and surgical interventions, which enabled necessary physical and psychosocial changes to be made. Such changes reduced instances of gender dysphoria and negative body image and, in turn, served to increase confidence, satisfaction and overall wellbeing.

Hormone usage had an extremely high success rate, with 90 % of users feeling more satisfied with their lives and 87 % feeling more satisfied with their bodies since initiating hormonal therapy. In relation to surgical procedures, 90 % of those who had undergone genital surgery reported feeling more satisfied with their bodies, and 83 % were more satisfied with their bodies after undergoing other surgical procedures such as breast augmentation or chest reconstruction. Of those who had made physical changes via hormones or surgery, 92 % reported having no regrets. However, participants highlighted the importance of having the right hormonal balance and receiving post-surgical care and support. Those waiting for surgical procedures or to start hormones highlighted the negative impact that delays had on their mental health.

Rates of self-harming, suicidal thoughts and suicide attempts were high, with 44 % of respondents having self-harmed, 78 % thinking about suicide and 40 % of those having attempted suicide at some point over the life course. However, gender transition was shown to drastically reduce rates of self-harm and suicidal ideation within this group. Of those who had completed transition, 76 % reported having self-harmed more prior to transition, but none of the participants had self-harmed more after transition. In addition, 81 % thought about or attempted suicide more before transitioning, but this amount was reduced to 4 % after transition among those who had already transitioned.

Whilst transition has been shown to significantly reduce rates of self-harm and suicidal ideation, it follows that those who would like to transition but who are unable to or who are experiencing significant delays or set-backs within the health care system will be at risk of increased self-harm and suicidal behaviour. Six percent of respondents reported currently selfharming at the time of completing the survey; 28 % had thought about taking their life in the last week; and one person said they were planning to commit suicide soon or in the near future. Trans-related reasons for participants’ self-harm and suicidal ideation included gender dysphoria, not having their gender recognised, social stigma, frustrations with treatment delays, lack of access to treatment, worry that they would never ‘fully’ or ‘successfully’ transition, having their identity misunderstood by health professionals and not feeling supported by gender identity specialists.

Author/-s:       Jay McNeil; Louis Bailey; Sonja Ellis; Maeve Regan

Publication:     Report by the Transgender Equality Network Ireland (TENI), 2013

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Transgender Emotional and Coping Processes – Facilitative and Avoidant Coping Throughout Gender Transitioning

Eighteen transgender-identified individuals participated in semi-structured interviews regarding emotional and coping processes throughout their gender transition. The authors used grounded theory to conceptualize and analyze the data. There were three distinct phases through which the participants described emotional and coping experiences: (a) pretransition, (b) during the transition, and (c) posttransition. Five separate themes emerged, including descriptions of coping mechanisms, emotional hardship, lack of support, positive social support, and affirmative emotional experiences. The authors developed a model to describe the role of coping mechanisms and support experienced throughout the transition process. As participants continued through their transitions, emotional hardships lessened and they used facilitative coping mechanisms that in turn led to affirmative emotional experiences. The results of this study are indicative of the importance of guiding transgender individuals through facilitative coping experiences and providing social support throughout the transition process. Implications for counselors and for future research are discussed.

Author/-s:       Stephanie L. Budge; Sabra L. Katz-Wise; Esther N. Tebbe; Kimberly A. S. Howard; Carrie L. Schneider; Adriana Rodriguez

Publication:     The Counseling Psychologist, 2013

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Psychological Well-Being and Level of Outness in a Population of Male-to-Female Transsexual Women Attending a National Transgender Conference

This study examined the relationship between psychological well-being variables (i.e., depression, anxiety, self-esteem) and level of outness in male-to-female (MtF) transsexuals. Participants were 105 MtF transsexual attendees at an annual transgender conference held in Atlanta, Georgia. Participants completed seven questionnaires, including the Demographics Questionnaire, the Outness Demographics Questionnaire, the Outness Attitude Scale, the Openness Scale, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and the Rosenberg Self-Esteem Scale. A canonical correlation was conducted with psychological well-being variables as the predictor and the outness variables as the criterion. Results indicated that psychological well-being variables are related to outness. Treatment implications, limitations, and suggestions for future research are discussed.

Author/-s:       Jeffrey D. Strain; I. Michael Shuff

Publication:     International Journal of Transgenderism, 2011

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Transgender children: more than a theoretical challenge

This research suggests that the majority of transgender people become aware of their gender identities at a very early age. As such many transgender children go through most, if not all, of their time in compulsory education knowing their gender identity is different from that expected of them. Transgender children are characterised as "apparent" and "non-apparent", with the vast majority being "non-apparent". It is argued that their concealment and suppression of identity for such a long period can lead to problems.

This paper examines this evidence and goes on to examine the implications of this from the point of view of children's abilities to rationalise and understand their own situations and make sense of the conflicting pressures on them to conform to gender normative behaviour and to expectations of gender which they are ultimately unable to do. As such they may spend many years of their lives unnecessarily having to deal with feelings of guilt and shame. The consequences of this are likely to be substantial underachievement in all areas of their lives.

Author/-s:       Natacha Kennedy; Mark Hellen

Publication:     Graduate Journal of Social Science, 2010

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Development and Initial Psychometric Evaluation of the Transgender Adaptation and Integration Measure (TG AIM)

Transgender individuals have a gender identity or expression that is not congruent with their anatomy (Bullough, 2000). Limited empirical data are available regarding the mental health and general well-being of the transgender population. In addition, few standardized measures have been developed specifically for transgender individuals. The main purpose of this study was item and scale development of a measure of adjustment for transgender adults, as well as the assessment of the internal consistency and validity of the measure. Responses to the Transgender Adaptation and Integration Measure (TG AIM) were collected from a sample of 108 self-identified male-to-female transsexual adults. Standardized measures of quality of life and self-esteem were also administered to participants in order to assess construct-related validity. Factor analysis of the measure identified four factors: Gender-Related Fears, Psychosocial Impact of Gender Status, Coping and Gender Reorientation Efforts, and Gender Locus of Control. Internal consistency for each of the four factors ranged from r = 0.59 to r = 0.81. Psychosocial Impact of Gender Status and Gender-Related Fears were positively correlated with self-esteem and quality of life. Coping and Gender Reorientation Efforts were significantly correlated to both Psychosocial Impact of Gender Status and Gender-Related Fears. Preliminary psychometric analysis resulted in a 15 item, multidimensional measure with three reliable and valid subscales for use with male to female (MtF) transsexual adults. Further psychometric evaluation of the measure for use with other segments of the transgender population is needed.

Author/-s:       Marie D. Sjoberg; Susan E. Walch; Claudia J. Stanny

Publication:     International Journal of Transgenderism, 2006

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The transsexualism syndrome: clinical aspects and therapeutic prospects

The prevalence rate of transsexualism varies from 1 to 50 000, to 1 to 100 000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients’ demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.

Author/-s:       T. Gallarda; I. Amado; S. Coussinoux; M. F. Poirier; B. Cordier; J. P. Olié

Publication:     L'Encephale, 1997

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Transsexualism in Germany: empirical data on epidemiology and application of the German Transsexuals’ Act during its first ten years

In light of possible emulation of the German Transsexuals' Act (TSG) in discussions taking place on future legislation in other states, on the 10th anniversary of the German TSG, we review the application of this law, as well as epidemiological data arising from its use. From 1981 to 1990, 1422 judicial decisions were rendered in Germany on this basis: 683 of them related to the so-called "small solution" (change of first name), and 733 involved what is termed the "major solution" (legal change of sex status). The frequency of transsexual applications over these 10 years lay between 2.1 and 2.4 per 100,000 German adult population. The average age was 33. Only 3.6% and 10.9% of the small and major applications, respectively, were rejected by courts. The sex ratio was 2.3:1 in favor of male-to-female transsexuals. Data revealed no significant trend over the years among the prevailing practices of adjudication, but evidence does exist that the German courts apply the law differently on a regional basis. Over the 10-year period, only six persons requested to have their names changed back again and only one to be reassigned to the former legal sex classification. Those who change their first names in the sense of a tentative accustomizing process waited an average of 2 years before changing their gender. Between 20 and 30% apparently went no further than the so-called "small solution."

Author/-s:       Cordula Weitze; Susanne Osburg

Publication:     Archives of sexual behavior, 1996

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Gender reorientation and psychosocial adjustment in male-to-female transsexuals

This study examined the relationship, in a sample of male-to-female transsexuals, between psychological and social adjustment, on the one hand, and gender reorientation (approximation of the status of the opposite biological sex), on the other. Three gender reorientation variables were studied: exogenous female hormones, vaginoplasty, and social feminization (adoption of the female gender role at home and in the transsexual's social life and the procurement of documents indicating the female sex). These three gender reorientation variables plus age were employed as predictor variables in a series of multiple regression analyses. Five stepwise regression analyses were carried out, one for each of five criterion variables (depression, tension, involvement with a male partner, cohabitation with a male partner, and the MMPI Lie Scale). There was a statistically significant negative correlation between depression and social feminization and between tension and social feminization, and a significant positive correlation between cohabitation with a male partner and vaginoplasty. Neither the MMPI Lie Scale nor the simple fact of having been "involved" with a male partner at some point during the past year correlated significantly with any of the predictor variables. These results indicate that gender reorientation is associated with better psychological and social adjustment in male-to-female transsexuals.

Author/-s:       Ray Blanchard; L. H. Clemmensen; B. W. Steiner

Publication:     Archives of Sexual Behavior, 1983

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