This paper is focusing on the findings of two longitudinal studies regards life satisfaction after transsexualism treatment for individuals with gender identity disorder (GID).
The present studies belong to different cultural and geographical areas, Germany (Ulrike Ruppin and Friedemann Pfa¨fflin, “Long-Term Follow-Up of Adults with Gender Identity Disorder”) and Sweden (Cecilia Dhejne , Paul Lichtenstein , Marcus Boman , Anna L. V.
Johansson , Niklas La?ngstro¨ m, Mikael Lande´n, „Long-Term Follow-Up of Transsexual Persons Undergoing Sex
Reassignment Surgery: Cohort Study in Sweden”)
Both of them are critically evaluated revealing the aims of the authors, their caracheristics, main findings as well as their methodological strengths and limitations.
Gender dysphoria or gender identity disorder according to DSM IV, is the desire of being the other sex. Often this leads to sex reassignment, a complex process that includes hormonal treatment and surgery in order to achive the desired gender.
Sex reassignment is being praticed for over halph a century in a international level and it is recognized as treatment for reducing gender dysphoria.
Short presentation of the studies:
The author’s aim for the first study was to test well being, social integration and the effectiveness in reducing gender dysphoria by comparing the questionnaires they filled in at the first contact with the clinic as well as other several standardized ones and interviews after a period of 10-24 years.
The sample of the study comprises 71 participants, patients from the Section of Forensic Psychotherapy at the Department of Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Germany in 2013.
This department was the first point of contact in the early 90″ for patients with gender dysphoria.
A quantitative and qualitative approach were used in order to compare psychosocial variables at the time of the initial consultation and at follow-up (approximately 10-24 years after their sex reassignment) in order to reveal the level of life satisfaction of the individuals.
The results of the follow up study reported high degrees of well-being of the participants. Significant differences were found on the scales of well-being and social interactions after sex reassignment in comparison with their initial consultation. An improvement of life satisfaction have started with changing their legal name according to their sexual identity before any other treatment.
The second study was made in Sweden in 2010, its aim is to determine the presence of mortality, morbidity and criminal rate for patients after sex reassignment surgery using a population-based matched cohort study.
The main feature of a cohort study is the observation of a large number of individuals over a long enough period of time to accrue a sufficient number of incident events to compare the risk of developing a disease in the exposed to that in the non-exposed.
The objective of the cohort study is to evaluate the association between a risk factor and an incident outcome-specifically, compare incidence rates in exposed and non-exposed groups.
The selection and observation of exposed and non-exposed groups is the traditional approach for a cohort study and is especially good when an exposure is rare.
The process of participant’s selections was complex and challenging. First of all medical records had to be screened and they were selected only if they met the following criteria:
- Their first contact with the clinic had to be at least 10 years ago
- To be diagnosed with Transsexualism at that time
- To have completed an official change gender role, including a legal name change according to German Law of Transsexuals
For all patients that met these criteria, letters were sent asking to contact the authors. When the letters were undeliverable, registration offices were contacted in order to check for the relocation addresses and to be sent again. This procedure was repeated till the letters did not come back as undeliverable, which means they reached the recipients.
For those who did not replied to the authors, a follow up letter was sent after 6 weeks distance from the original letter. In total 140 letters were sent, 101 replied and 71 person accepted to participate to this study. 46 of them were invited to participate to the study at the clinic and 10 were visited at their own residence. 15 of them lived to far so they could only answer to the questionnaires that they were send by email.
Many from the selected persons did not participated from various reasons: 39 persons did not replied to the authors for unknown reasons, for other 9 persons the relocation address were unknown, 2 persons had meanwhile passed away, 8 did not wanted to take part of the study, 5 declared they are somatically sick, 8 others declared they don’t want to participate as transsexualism is not an issue for them anymore.
For the 71 participants that agreed and were able to attend, they were interviewed in regards the following topics: well-being, treatment, work, family, friendship, partnership, sexuality and gender role.
Participants of the second study are in total 324 sex-reassigned persons (191 male to female and 133 female to male), between 1973 and 2003 and they were chosen randomly from the National Register of Sweden using their registration number as primary key.
The national registration number it is assigned to all Swedish residents including immigrants on arrival. It consists 10 digits where the first 6 provides information regards date of birth and the ninth digit indicates the gender.
In Sweden, patients diagnosed with gender dysphoria is referred to one of six specialized gender teams in order to evaluate and treat them according to Standards of Care who are used as International guidelines.
Once the patients receive their medical certificate, he/she can apply to the National Board of Health and Welfare in order to start the sex reassignment process. The first step is changing the legal sex status at after the sex reassignment surgery, the patient will receive a new registration number according to the new gender.
The Board of Health and Welfare maintains a link between these two registration numbers and make these follow up studies possible by identifying individuals undergoing sex reassignment.
There were used 2 criteria in order to identify the participants of the study:
- Individuals diagnosed with gender dysphoria without concomitant psychiatric diagnoses in the Hospital Discharge Register
- Individuals with discrepancy between gender variables in the Medical Birth Register and Total Population Register, starting with 1973
These were used to ensure the participants meet the criteria for the aims of the present study.
Using the above criteria, a number of 804 patients were identified but 324 presented a shift in gender variable from 1973 and onwards.
There was used, as well, population-base controls (unexposed group) for each of the exposed persons. So 10 randomly selected unexposed controls were selected for each of the 324 exposed persons.
The unexposed group had also to meet the following criteria:
- Had no discrepancies in sex in Medical Birth Register and Total Population Register
- Had no diagnose as gender dysphoria
- Had to have the same sex, birth year to be alive and residing in Sweden at the estimated sex reassignment date as for the case person
There were used 2 controls groups in order to reveal any specific effects on outcomes of interest, so for each participant of the study they were a man and a woman matching their old and new gender, having the same birth year.
Data collection method:
A combination of qualitative and quantitative methods as semi-structured interviews and several standardized questionnaires were used in order to reveal life satisfaction before and after sex reassignment.
All interviews were tape recorded and were conducted by a postgraduate researcher that had no contact with the participants any time before.
The standardized questionnaire were completed at the first contact with the clinic and they were now re-administered and the result were used to compare psychological variables.
The following questionnaires were also applied:
- The Symptom Checklist (SCL-90-R) (Derogatis, 1977 s, 1977;German version by Franke, 1995, 2002)- evaluating a broad range of psychological problems and symptoms of psychopathology.
- The inventory of Interpersonal difficulties (IIP) (Horowitz, 1999; German version by Horowitz, Strauß,&Kordy,2000) – measures distress arising from interpersonal sources
- BEM Role Inventory , (Bem, 1974; German version by Schneider-Du¨ker, 1978)- measuring Gender role stereotypes
- Freiburg Personality Inventory, a German personality questionnaire (testing the scales for: Life satisfaction, Social orientation, need for achievement, shyness, irritability, aggressiveness, stress, physical troubles, health sorrows, openness, extraversion and emotionality, (FPI-R) (Fahrenberg, Hampel, & Selg, 2001)
For the study made in Sweden, a cohort study was used in order to determine mortality, psychiatric morbidity, accidents and crime after sex reassignment. They were taken in consideration as well any criminal conviction during follow-up.
Everyone of the selected individuals contributed to the present study until the end of it or till death/emigration, whichever came first.
Quantitative data was analyzed using SPSS 20 for Windows and qualitative data was performed using ATLAS ti. Due to financial reasons and time constraints, only 33% of the interview material were coded. As result, the interviews were gathered, they were abstracted and then transcribed.
For the second study, statistical analyses was used hazard ratios (HR) with 95% confidence intervals (CI) in order to measure the association between exposure and outcome meaning sex reassignment and rate of mortality, morbidity and crime. All data was analyzed using SAS version 9.1.
These results, unlike other follow-up studies (Pfafflin and Junge- 1992, 1998), do not reveal any desire for gender role reversal. Participants were satisfied with their own appearance and expressed a little doubt about their gender role.
Even if scores regards their sexual live was moderate to high level satisfaction, these scores are lower than in other areas. Other studies reveal that some of the people with sex reassignment have a high sexual satisfaction meanwhile others do not. The reasons for the second category are unknown.
Other interesting facts reveal by the present study was that male participants mentioned having mostly heterosexual contacts while homosexual experiences were more common for the female participants.
Many studies have revealed a great deal of variability in sexual orientation for people with sex reassignment, both man and woman.
Positive findings were related to the professional area as well as relationship with family and friends.
In regards the need of psychotherapy ( The international Standards of Care-World Professional Association for Transgender Health, 2011 recommends psychotherapy to patients with GID), participants experiences were mostly negative due to lack of knowledge on the therapist side.
Male as female participants reported complications post sex-reassignment surgery but experience revealed that the role of the surgeon it is very important and patience’s must be informed before making a choice. These data is congruent with the ones from other studies and clinicians advice is to prepare patients for all possible complications post-surgery.
The second study reveals that sex-reassignment individuals both genders had approximately a three times higher risk of all-cause mortality than controls groups.
Suicide as cause-specific mortality was as well much higher for the sex reassignment individuals compared to control groups.
Mortality due to cardiovascular disease was moderate for sex reassignment individuals, while mortality for malignancies (lung cancer, tongue cancer, pharyngeal cancer, pancreas cancer, liver cancer etc.) were found to be statistically increased.
Risks for being hospitalized for psychiatric disorders were four times more often than for control groups.
Risk of suicide attempts was also found to be also higher for the sex reassignment individuals compared to matched control groups.
In regards the crime rate was found a significant increased risk of being convicted for any crime or violent crime after sex reassignment surgery but only for patients before 1989.
Hazard ratio measurement indicates a higher risk for suicide attempts for male-to-female patients compared with both male and female control groups. Female-to-males, on the other hand, were found to have a significantly increased risk of suicide attempts but only compared with to male controls.
Taking in consideration that man are more likely than woman in the general population to commit violent crimes, according to the present study, male-to-female have an increased risk compared to female control group, but not to males groups. This conclusion indicates that in regards criminality, male-to-female individuals retained a male pattern after the sex reassignment.
It was also found that female-to-male have higher violent crime rates than female controls but not different from the male matched control. This conclusion indicates a shift to male pattern in regards violent crimes.
Strengths and limitations:
Both studies have strengths and limitations.
For the first study, result of standardized questionnaires points out an important aspect regards the psychological problems and interpersonal difficulties from the initial consultation in comparison with the ones from follow-up. Though results might be different due to the fact that personality traits become more stable over time.
Opposed to this is the gender role stereotype who remained stable over time considering the first consultation and follow up. This result might due to the fact that most of the participants had already started the process of transsexualism.
The authors conclusion is that the follow up questionnaires, interviews and standardized questionnaires revealed a greater number of positive and desired changes rather than complications and negative experiences.
The authors points out that numerous studies were made with shorter follow-ups and they have also demonstrated positive outcomes after sex-reassignment but even so, transgenderism has a lot of gaps and limits and requires improvement.
The article has its strengths taking in consideration that it is a longitudinal study as well as the sample includes only people who were diagnosed with gender dysphoria. The participants were up for the sex-reassignment surgery in yearly 90’ with all the risks and difficulties that were involved in this complex process and also considering that the transgender medicine was still in need of improvement back then.
The positive outcome of the study may be culture specific, a segment of transgender identities who cannot be considered worldwide valid. That is, certain relations between factors as gender identity and well-being but may apply only to individuals who belong to a culture similar to the one that the participants of this study do. As example a study made in USA (Heidi M. Levitt and Maria R. Ippolito, 2014) has found a great number of negative impacts on this category that are facing systematic oppression – for instance, employment discrimination, social prejudices.
Another limit might be the approach of the study as they focused their resources more on the selection of participants than the measures of the outcomes. The authors mentioned about the qualitative analyses that due to financial reasons and time constraints, it was not possible for them to transcribe the complete interviews. Relevant data may be lost within this project.
Also due to the long follow up, participants may forgot some events that happened in their lives and give positive e answers according to their present situation.Another important fact is that the non-responders are the ones that had less favorable scores at the first consultation and maybe their vulnerability and negative experiences made them less motivated to participate to the study. Their absence from the study might affect and limit the reliability and validity of the study.
Also, bias answers might be possible at their first contact with the clinic if they thought favorable answers will increase their chances to get treated. A positive thing about the study is that the quantitative and qualitative data complete each other developing a bigger picture in regards wellbeing of gender dysphoria patients. Though some of the outcomes might be subjective as the interviewed person is likely to answer positively in order to meet the expectations of the interviewer. In regards questionnaires, respondents might lie due to social desirability.
Another positive aspect of the study is the methodology used for the measurement of quantitative data in congruence with the purpose of it.
The positive outcome of the study might be due to the conformation on the patient’s side. Their experience might’ve been negative but anyhow less negative or traumatic than before sex reassignment.
The strength of the second study is the sample of participants which includes almost entire population of Sweden of sex-reassigned individuals, starting with 1973 till 2003. All individuals who participated at this study had a sex-reassignment surgery and there were used control groups matched by birth year for both birth sex and after sex reassignment surgery.
Even if the present study is population-based matched cohort study with long-term follow up and results are statistically proven, the study has his own limitations, first as Sweden is a small country (9.2 million inhabitants in 2008) and the statistical power is limited but and also for the fact that no correlations between causes and result were possible to interpret as no reliable data were available.
Although sex reassignment alleviates gender dysphoria, the diagnosed individuals have higher risks for mortality, suicidal behavior and psychiatric morbidity than the general population. Another limitation is that the outcomes measures were made exclusively after the sex reassignment. In order to reveal the impact of sex reassignment both data: “pre” and “post” surgery is needed.
The study does not points out that sex reassignment it is causing any of the researched topics as: morbidity, mortality and criminal rate. Considering the findings of the study, things might’ve been worse without sex reassignment. Still even if surgery and hormonal treatment have improved with time, there is a great need of attention for psychosocial care in regards individuals diagnosed with gender dysphoria and sex reassignment.
The cohort study has his own advantages as offers clarity of temporal sequence, allow calculation of incidents. Also cohort studies reduce the possibility that the results will be biased by selecting subjects for the comparison group who may be more or less likely to have outcome of interest.
Each one of the studies has his own importance in understanding sex reassignment individuals but also their limitations which were observed and explained in all the above.