| Katherine Rachlin, "Transgender Individuals' Experiences of Psychotherapy", American Psychological Association, 25 August 2001 |
| | Psychological evaluation should be distinguished from psychotherapy and should not be a substitute for therapy when needed. It may be important to distinguish between psychological assessment and psychotherapy and make sure that the client has realistic expectations. People were satisfied when they came for a letter and left with a letter. They did not necessarily experience personal growth, increased insight, or help with life decisions. Individuals do not usually expect to get personal benefit from diagnostic tests, beyond their diagnostic capabilities. It might be realistic to have similar expectations of psychiatric assessment prior to gender reassignment. |
| | Though in many cases the most helpful treatment is surgical, there is no reliable diagnostic test that a physician might prescribe to assess the appropriateness of such a patient for surgery. Most of the known correlates of post-surgical success are psychosocial and are best assessed by a trained clinical behavioral scientist. The incidence of postoperative regret is generally extremely low (Pfäfflin (1992) found less than 1% in Female-to-Males and 1-1.5% in Male-to-Females). However, researchers continue to study incidents of regret in an effort to decrease the occurrence even further. A better understanding of the factors which contribute to both postoperative satisfaction and postoperative regret will enable clinicians to improve diagnostic and selection criteria and presurgical preparation. |
| Walter Bockting, Eli Coleman, "A comprehensive Approach to the Treatment of Gender Dysphoria", J of Psychology & Human Sexuality, 5:4 1992, pp. 131-153 |
| | Sex reassignment may be recommended but only after identity development tasks have been addressed. |
| | Implying sex reassignment early on precludes the exploration of cormorbid psychopathology and of the various dynamics and motivations for sex reassignment. This approach has potentially disastrous consequences given the irreversibility of hormonal and surgical sex reassignment. |
| | Involving family members (both current family and family of origin) early in treatment is extremely helpful. Often the family helps put the clients gender dysphoric feelings in perspective of their psychosociosexual development. Family members may provide information that the client did not consider relevant, was unaware of, or held back in fear of rejection for sex reassignment. |
| | In cases of significant childhood abuse and continued patters of victimization, participation in a short-term group for victims of childhood abuse is recommended. |
| | In three months not much more can be expected than establishing a therapeutic relationship as a prerequisite to the necessary psychotherapy. Again, many clients who present with a desire for sex reassignment are in crisis and often are obsessively focused on sex reassignment. We recommend a minimum of six months of ongoing psychotherapy before the onset of hormone therapy. |
| | By working through his or her biography, the client and therapist can put gender dysphoria into a context of broader identity development. This is helpful in determining realistic therapeutic goals, and can clarify the potential of sex reassignment in the process of identity integration. |
| | While many clients who present with gender dysphoria meet DSM criteria for gender identity disorders, simply focusing on these disorders ignores the complexity of an individual's psychosexual and psychiatric history. This is particularly true for those who meet criteria for transsexualism. For many clients as well as professionals, this diagnosis presupposes sex reassignment as the treatment of choice. |
| | In our experience, the gender dysphoric client's distress cannot be completely attributed to the perceived gender identity conflict or to a history of gender nonconformity. These are important factors, but disposition and life experiences relatively unrelated to gender also determine the client's current adjustment, and may contribute to the desire for sex reassignment. |
| | The authors argue for a comprehensive treatment model that recognizes a wide spectrum of gender identity disorders. This treatment model explores the meaning of a gender dysphoric individuals desire for sex reassignment in the context of the individual's biography and psychosociosexual adjustment. Unlike previous treatment approaches, this model makes no attempt to identify the 'true' transsexual. |
| | Symptoms of anxiety and depression form a barrier to engaging in psychotherapy. We have found the serotonergic anti-depressant fluoxetine (Prozac) and the mood modulator lithium carbonate, extremely helpful in alleviating these symptoms. In addition to facilitating engagement in psychotherapy, these medications may decrease the intensity of the dysphoria, relieving what is often an obsession with obtaining hormonal and/or surgical sex reassignment. |
| | We are cautious about treating the gender dysphoric client's despair due to co morbid psychopathology with sex hormones, and prefer to try other medications specifically developed for this purpose. We are concerned about how the client constructs his or her identity after being given male or female hormones. This may force a premature consolidation of a cross gender identity and may intensify the desire for surgical sex reassignment. |
| | Often gender dysphoric clients have a more ambiguous gender identity and are more ambivalent about a gender role transition than they initially admit. It is common for the client to seek assurance form the clinician through confirmation of a diagnosis of transsexualism. Our treatment model challenges clients to review their motivations for solutions to their gender dysphoria and to think creatively regarding identity management. This allows gender dysphoric clients to discover and express their unique identity, as opposed to adopting a stereotypical one out of their intense need to conform. |
| | The classification of gender identity disorder in itself should not imply a prescribed solution. |
| Peggy Cohen-Kettenis, Bram Kuiper, "Sex Reassignment Surgery: A study of 141 Dutch Transsexuals", Archives of Sexual Behavior, 17:5 1988, p. 439 |
| | The care provision system should carefully pay attention to psychosocial guidance in addition to medical guidance. |
| | More attention ought to be paid to psychosocial guidance in addition to medical guidance. |
| | A number of persons need more specific, more frequent psychosocial aid and support in the process of reassignment. |
| Michael Ross, William Walters, "Transsexualism and Sex Reassignment", Oxford University Press, 1986 p5 |
| p5: | Levine suggest that up to 70 per cent of their transsexual patients, following long-term psychotherapy, do not want gender reassignment surgery. Similarly, Morgan has commented that of presenting transsexuals 10 percent will have a major mental illness, 30 percent will be homophobic (anti-homosexual) homosexuals, and 20 to 25 per cent will be sexually inadequate individuals with ambiguous gender identity. The remaining 35 to 40 per cent will probably be individuals with primary gender dysphoria, for whom gender reassignment surgery may be the treatment of choice. |
| L. Lothstein, "Psychological Testing with Transsexuals: A 30-year Review", Journal of Personality Assessment, 48:5 1984 |
| | As critics reconsider the DSMIII diagnostic criteria for transsexualism, as research continued to suggest that psychotherapy, not surgery, is the treatment of choice for transsexualism and as newer theories of transsexualism (stressing the linkage between transsexualism and borderline disorders) are presented, clinicians will have the opportunity to restructure the role of psychological testing in transsexualism (focussing on assessment rather than prediction). |
| Laura Roberto, "Issues in Diagnosis and Treatment of Transsexualism", Archives of Sexual Behavior, 12:5 1983, p. 445 |
| | Those who view transsexualism as a delusional belief reflecting emotional conflict feel that transsexuals may be accessible to psychotherapy. |
| | Researchers who believe that transsexualism represents a crystallized gender identity transposition, fixed during a "sensitive period" in childhood, hold little hope for a psychological means to reverse it. |
| L. Lothstein, "Sex Reassignment Surgery: Historical, Bioethical and Theoretical Issues", Am J Psychiatry, 139:4 April 1982, p. 417 |
| | Most clinicians who recommend sex reassignment surgery as the treatment of choice also tend to believe that psychotherapy is useless with gender dysphoric patients. |
| | Throughout the 1970s increasing numbers of patients sought sex reassignment surgery. Many of these clients were secondary transsexuals who, under stress, expressed a regressive wish for sex reassignment surgery. Spurred on by changing views of societal sex roles, large numbers of patients were given external support to change their sex rather than to understand the nature of their psychological distress. |
| | There is evidence suggesting that some gender dysphoric patients benefit primarily from sex reassignment surgery. Most such patients, however, are secondary transsexuals who can benefit from various modes of psychotherapy. |
| | sex reassignment surgery is not a cure for psychopathy |
| | The studies of the 1970s and early 1980s challenged the idea that sex reassignment surgery was a cure for transsexualism. While prior findings that sex reassignment surgery leads to better socio-economic functioning for some patients were given additional support, gender dysphoric patients were characterized as having severe psychopathology that was unaltered by sex reassignment surgery. As an outgrowth of these studies, it was suggested that candidates for sex reassignment surgery receive preoperative and postoperative counselling and/or psychotherapy. |
| | Most gender dysphoric patients are secondary transsexuals who can benefit from various modes of psychotherapy. |
| | Many patients who would have otherwise undergone sex reassignment surgery may adjust to a nonsurgical solution through psychotherapy. Moreover, many misdiagnosed gender dysphoric patients need psychotherapy, not surgery. Indeed, sex reassignment surgery should only be considered as the last resort for a highly select group of diagnosed gender dysphoric patients. |
| Stephen Levine, L. Lothstein, "Expressive Psychotherapy With Gender Dysphoric Patients", Archives of General Psychiatry, August 1981, p. 924 |
| | Of 50 gender dysphoric patients, 70% have adjusted to nonsurgical solutions, 20% are receiving treatment and 10% have received SRS and psychotherapy. |
| | Most SRS applicants are not primary transsexuals (some of whom may benefit from surgery), but secondary transsexuals whose cross-gender wishes are regressive. These latter patients also have been described as nonsurgical transsexuals or nontranssexual men and women who need psychotherapy, not surgery. However these patients are often referred for SRS because of misdiagnosis and misunderstanding by clinicians regarding their disorder. |
| Anke Ehrhardt, Heino Myer-Bahlburg, "Effects of Parental Sex Hormones on Gender-Related Behavior", Science, 20 March 1981 |
| | Once gender identity has been established, it cannot be reversed easily. In the first few years of life a child's gender identity is usually embedded firmly. |
| L. Lothstein, "Psychodynamics and Sociodynamics of Gender Dysphoric States", American Journal of Psychotherapy, 33:2 April 1979 |
| | Permission to engage in role reversal has, perhaps unwittingly, been turned into a license for sexual reversal. |
| Virgina Prince, "Transsexuals and Pseudotranssexuals", Archives of Sexual Behavior, 7:4 1978, pp. 263-283 |
| | I think that professionals in the various branches of medical science dealing with these matters should learn to distinguish between the concept of sex and the concept of gender and thus between the motivations their patients have; they should look at the long term effects rather than the short term fantasies and demands; and they should attempt to minimize the discussion of this type of surgery in the public media in the interest of lessening the number of persons "turned on" to the idea and who then swell the ranks of the "ladies in waiting". For ever one person for whom surgery is indicated there are at least nine others for whom it is not and who, if they had never heard, read or seen something about sex surgery would never have "gone the route" themselves. I have watched too many of my friends and acquaintances go down the tubes, breaking up marriages and homes along the way, all to accomplish what? The opportunity to live their own chosen life style which they could have done anyway. |
| James Morgan, "Psychotherapy for Transsexual Candidates Screened out of Surgery", Archives of Sexual Behavior, 7:4 1978, p. 273 |
| | Before we embark on the mission of helping the male-to-female transsexual to be a woman or the female-to-male transsexual to be a man, we must begin to explore the necessity of the candidate to develop as a person-no small task for anyone. |
| | Most patients present with a demand for surgery which I have called the "transsexual imperative." Upon evaluation, the entire spectrum of psychiatric disorders is seen in this patient group, and for most, transsexual surgery is not indicated. |
| | Most of the time, operative intervention is not required or desirable, and vigorous efforts must be made to redirect the patient into more appropriate channels. Even when surgery appears indicated much psychotherapeutic work must be done before and after the surgery to help the patient adapt to his or her new role. |
| Lawrence Newman, Robert Stoller, "Nontranssexual Men Who Seek Sex Reassignment", Am J Psychiatry, 131:4 April 1974 |
| | In the earlier days, when the emphasis was on the normality of transsexuals, the idea of using psychotherapy in any of its forms, whether psychoanalytic psychotherapy or behavior modification, was discarded on the basis that it was either not needed or was fruitless. I think it is a fairly well accepted fact that in most specialties of medicine that just because there is a state of chronicity or malignancy that fails to respond to the available treatments in the field, it nevertheless may properly belong in the diagnostic categories of that field. |
| Lionel Oversey, Ethel Person, "The Transsexual Syndrome in Males II. Secondary Transsexualism", American Journal of Psychotherapy, 1974 |
| | Their willingness or unwillingness (to undergo psychotherapy) should not be the determining factor in laying down sound medical procedures. |
| | The situation is different, however, with both homosexual and transvestic transsexuals who comprise the majority of applicants for sex reassignment. Instead of being transformed into bona fide transsexuals, these patients could end up simply as castrated homosexuals and transvestites with all their attendant problems unresolved and the means for coping with these problems surgically removed. |
| | Every patient, at minimum, should receive an extensive psychiatric evaluation and, if at all possible, a trial of psychotherapy. If this fails to stabilize the patient, sex conversion cannot be ruled out, but neither should it be recommended unless the patient meets certain criteria. |
| Ira Pauly, "Female Transsexualism Part II", Archives of Sexual Behavior, 3:6 1974, p. 509 |
| | Despite the strides forward which we have made in our understanding and treatment of this condition, all would agree, including the transsexual, that transsexualism would be far better prevented than treated. |
| Ira Pauly, "The Current Status of the Change of Sex Operation", The Journal of Nervous and Mental Disease, 147:5 1968 |
| | At the present time one is impressed with the lack of success in attempting to alter gender identity, once established, by traditional psychotherapy. This fact, together with the apparent success of sex reassignment surgery, compels one to accept the surgical treatment of transsexualism on an experimental basis until the initial results can be verified or contradicted or until alternative treatment procedures prove successful. |