Gender Dysphoria: A Guide to Research (1994)

Gender Dysphoria is dedicated to Lili Elbe (1882-1931), a Danish painter who underwent surgical sex reassignment in Weimar Germany. The last procedure caused her death.

Preface

An Elephant is Like a Tree

Lay people often think that scientists have vast secret sources of wisdom. The truth of the matter is that while the things that science has accomplished are astonishing and perhaps even miraculous, the accumulated knowledge of science does not at first glance seem impressive. It lies, for the most part, in articles which appear in professional journals. There are other methods of communicating science, of course. Important or significant journal articles are often expanded into chapters in edited books and eventually find their way into textbooks or are listed in bibliographies like this one. Special interest groups meet periodically, sharing information via posters (which are essentially journal articles pasted onto poster board, with the authors handy to answer any questions) and papers, which are generally short (20 minute or so) oral reports of ongoing research which may eventually turn into journal articles. But it is in the journals that the hard body of science lies.

Journal articles range in length from one to more than a hundred pages, but the average is perhaps 7-10 pages. Into this short space, the authors must cram an abstract (a one-paragraph summary of the article), an introduction, and a reference list, as well as the methods used and the results, and a discussion which explains the significance of the findings to science and to humankind.

What’s wrong with this picture? Well, the problem is that science is rigorous and complex, and there is simply not enough room in a journal article to explain methodology sufficiently to allow reliable replication. This is especially true in the social sciences, in which there are typically many uncontrolled and uncontrollable variables. Because of lack of space, critical information about these variables and about procedure is omitted in journal articles. At best, the reader gets a vague notion of what actually transpired and can partially replicate the experiment. At worst—well, scientists are human, and, despite their best efforts, their work is often plagued with inconsistency, unconscious bias, faulty or inappropriate application of statistical methods, and conclusions which do not follow from or go beyond their data.

The fact is, the subject matter of the social sciences is often so sloppily presented that it is difficult to be sure of anything. It is possible to find serious methodological flaws in many, and perhaps the majority of reports, and those which do not have such faults are generally unreplicated. Whatever one’s bias or viewpoint, it is easy to find research (however poorly done) to support it or to support it by generalizing findings inappropriately.

The biggest problem in the social sciences, however, is that scientists often presume and act as if what is not present in the information base cannot be true; i.e., as if absence of evidence is evidence of absence. Instead of meticulously and carefully building an information base, we proceed as if the few shards of knowledge we possess are absolute and complete truths, even when those shards do not allow us to see the shape of the pot. When this sort of arrogance is used to make decisions about the lives of human beings, the results can be tragic. Have been tragic.

In his excellent book The Mismeasure of Man, Stephen Jay Gould discusses real-life instances in which scientists subconsciously allowed their personal views and biases to color their data, the conclusions they drew from that data, and even the research questions they asked. From a vantage point of nearly a century after the events, his observations about bias and dehumanization in the mental measurement movement seem obvious—but they were not apparent when the research was new, as today’s biases will not be apparent for years to come.

The wise person realizes that most of what can be known by science has not yet been discovered and that to place excessive reliance on the accumulated body of knowledge of the social sciences, a shaky tower at best, is more an act of faith than science. And yet life-altering and civilization-altering decisions are made and policies formulated on this information base—and often on biased interpretations of it.

Certainly, this has been the case in regard to transgendered persons—those who do not fit securely in either of the two gender boxes allowed by our society. The widespread and sudden acknowledgement of transsexualism—a phenomenon unacknowledged until the 1950’s—gave scientists an unparalleled chance to investigate and explore it in the rational and careful manner which characterizes good science. In preparing this book, it became clear to me that this did not occur; rather, the literature developed in a haphazard and reactive and highly visceral fashion, as scientists tried, often unsuccessfully, to maintain objectivity in the face of their personal feelings about this highly emotional issue.

To be fair, the “arrival” of transsexualism, which coincided with the 1952 return to the United States of Christine Jorgensen, who had received surgical and hormonal sex reassignment in Denmark, resulted in both a profound paradigm shift and a pressing practical need. Maleness and femaleness could no longer be considered to be immutable (the paradigm shift), and physicians and psychologists found themselves facing considerable numbers of men and women demanding hormonal and surgical sex reassignment (the practical need). The literature which arose was, therefore, a reaction to these twin dilemmas. There were definitional and ethical problems which had to be resolved, and there was a need for descriptive studies, treatment guidelines, outcome studies, and explanations of surgical and hormonal procedures used in sex reassignment. Consequently, much of the past and even much of the present literature of gender dysphoria is treatment related, what I have called elsewhere “a collection of papers by clinicians explaining to other clinicians how to deal with such troublesome people” (Denny, 1993).

Transsexual people are described as the clinicians see them; often, in desperation, requesting services which only the clinician can authorize or perform. But while clinical studies have taught us much, there is much more to what Harry Benjamin (1966) called “The Transsexual Phenomenon” than reports of the interactions of human beings in a highly artificial setting in which services are traded for money. What has been lacking in the literature of gender dysphoria is what has been lacking in the literature of psychology in general—a broad base of observational studies upon which to build.

Dr. William Verplanck, one of my graduate professors, often remarked that unlike biology, a science built upon painstaking observation and classification, psychology began in a wild spate of theorizing. Because these theories were not based on a wide range of evidence, most ultimately imploded—unlike biological theories like Darwin & Wallace’s theory of natural selection, which has endured for more than a century. So, too, did pronouncements about gender dysphoria begin to arise, based upon fragmentary evidence or, more often, upon bias and prejudice hiding behind fragmentary evidence. Transsexualism came to be seen as a medical condition requiring treatment and transsexual people as “sick.” Few researchers bothered to look at the phenomenon of transsexualism outside of the treatment setting. Few bothered to look beyond the shards at the shape of the pot.

Anne Bolin’s doctoral dissertation, which was published in 1988 in book form under the title In Search of Eve: Transsexual Rites of Passage, was an ethnomethodological look at male-to-female transsexual persons exclusive of the treatment setting. With this simple reframing, she found not only that many of the clinical “wisdoms” about transsexual persons were untrue but that the adversarial nature of the client-caregiver relationship affected the information which transsexual people gave to the caregivers. Transsexual persons’ notions about the biases of the caregivers affected their presentations, which affected the biases of the caregivers, which, in turn, affected the presentations of the transsexual persons. Practically all of the literature about transsexualism came from those involved in this cycle, who were for the most part unaware of it. The cycle was visible to Bolin simply because she was not part of it.

Bolin’s study was of limited scope, and she has made it clear that she does not feel that her findings should be generalized to all transsexual persons. The true significance of her work is that it illuminates the myopic nature of much of the literature of transsexualism and shows us that we need to build a base of general information about persons with gender dysphoria so that we can more sanely and reasonably approach their treatment; else we will all be blind men standing in the same place, trying to determine the nature of an elephant.

William Jennings Bryan was unfortunate enough to have said in the Scopes Trial, “I do not think about things I do not think about” (Grebstein, 1960). Science is by far the most powerful intellectual tool devised by mankind. But we need to learn to think about things that we do not think about.

Source: Dallas Denny. (1994). Acknowledgements. In Gender dysphoria: A guide to research, p. xiii. New York: Garland Publishers.

 Acknowledgements

This bibliography represents a great deal of effort both on my part and on the part of others. It would not be available in book form without Dr. Vern Bullough, who encouraged me to publish it and laid the groundwork at Garland Publishing. He kindly agreed to write the introduction and gave me permission to incorporate material from his own bibliographies. He has always answered the questions of a novice bibliographer promptly and courteously.

I would also like to thank Dr. Phyllis Korper, my editor at Garland Publishing, for her suggestions and assistance.

I would like to acknowledge Walter J. Phillips of Paths Untrodden Books in New York for allowing me to use his catalog descriptions for books which I have not seen. I would like to thank those who, knowing of the bibliography project, sent me articles and references. But most of all, I would like to thank those who wrote and referenced the works I have cited; they did the real work.

Source: Vern Bullough. (1994). Foreword. In Dallas Denny, Gender dysphoria: A guide to research, pp. xv-xix. New York: Garland Publishers.

Foreword

Vern L. Bullough

Transgender behavior, gender dysphoria, crossdressing, transvestism, transsexualism (both preoperative and postoperative), and numerous other terms are now used to describe a phenomenon that is perhaps inherent to the human condition. At its simplest it is a desire to fantasize how it would be to have been born a member of the opposite sex, and at its most complex it is a desire to become a member of the opposite sex, and there are all sorts of variations in between. Such a phenomenon was not described and classified until 1910 by Magnus Hirschfeld who coined the term transvestism to describe a variety of cross-dressing behaviors that came to his attention. Included in his descriptions of cases were individuals who were homosexual, heterosexual, and what he called autosexual although most were classified as heterosexual. Also included in his cases were individuals who later would be classed as transsexuals while still others would be called fetishists. His English contemporary Havelock Ellis wanted to be more specific and reserve the term for heterosexual males who cross-dressed, and he coined the term eonism, after the Chevalier d’Eon, an eighteenth-century Frenchman who had lived the last part of his life as a woman. Hirschfeld’s more neutral term came to be preferred because it could refer to both men and women and seemed, at least for a time, to be more inclusive.

For many years after Hirschfeld and Ellis wrote, trans­gender behavior was mainly discussed in medical literature, particularly that written by the psychiatric wing of the medical community. Most of these writers conceptualized vari­ations from the norms of sexual behavior as an illness, and they attempted to explain the nature or cause of the disease and to offer treatment.

Giving new impetus to transgender studies was the case of Christine Jorgensen, whose “surgical” transformation from man to woman was a media sensation in 1952. Some of the confusion about transgender behavior at that time appears in descrip­tions of Christine, who in the original professional literature about her was described as a transvestite and not a transsexual although that term had also been recently invented. There was also considerable misinformation about her since technically she was not transformed into a female but had her scrotum, testicles, and penis removed. Only years later was there an attempt to construct a vagina for her. Jorgensen, however, could be feminized because by the time of her surgery several of the sexual hormones had been isolated, and she was given enough estrogen that she soon became very feminine looking. Thus, although amputation of the male genitalia had long history, and hysterectomies and breast removal had been done since the turn of the century, it was only when inexpensive hormone supplements were available at the end of the 1940s that surgical reassignment came to be the ultimate medical solution to problems of gender dysphoria in both sexes. Jorgensen was not the first to change her sex, but she became the most famous and her action led almost immediately to thousands of others seeking a surgical sex reassignment. To give some guidance for such surgery, Harry Benjamin and others worked to establish procedures and regulations for sex change surgery. One of the effects of the guidelines, however, was to give elements of the professional community veto power over those who wanted to change their genitalia to conform to what they felt was their true sex. Undoubtedly this tended to lessen the potential for poorly thought-out decisions, but it also made it necessary for those seeking surgery to pass through a series of barriers not all of which were necessary. At the same time it encouraged the growth of surgeons willing to operate without careful consider­ation or consultation with psychiatrists. Some of the best surgeons operated more or less independently of the system, but then so did all of the worst.

The great importance of the Jorgensen case, however, was not that she popularized what is now known as transsexualism but that she gave courage to others in the cross-gender commu­nity to speak and act for themselves about their gender identity.

As the distinction between transvestites and transsexuals became formalized, individuals such as Virginia Prince em­phasized the potential of male heterosexual transvestism. One result of her efforts was the growth of organized groups and clubs for cross dressers. As people moved out of their transgender closet, they found there were a lot of others who had the same feelings and behaviors they did, but they also found that not all were exactly the same. Though large numbers were hetero­sexual others were homosexual, a few asexual; some liked to only partially dress, others more completely, and some wanted to live full time in the opposite gender while others were satis­fied with only an occasional episode of cross-dressing. Though male cross-dressers far outnumbered female, it was also more difficult to document this since women in general had more freedom in their dress than men, and unisex clothing for the most part had been modeled on male clothing, not female. Female-to-male surgical sex reassignment remained less than male-to-female but as techniques were perfected, the numbers of females began to approach male levels.

As the medical and psychiatric community struggled to define a variety of transgendered behaviors, others in the helping professions such as social workers, nurses, and psychol­ogists joined with them. Challenging much of the research, however, were scholars and individuals from other disciplines and approaches such as anthropology, history, and sociology. Many of these, following the changes in professional attitudes toward the nature of homosexuality and the realization of the bisexual potential which existed in all of us argued that there were societal and cultural variables that needed to be con­sidered in cross-gender behavior. Many of the more radical of those who approached the topic, such as myself, have argued that genitalia is not necessarily the mark of one’s gender identity. Throughout history vast numbers of women have lived and acted as men while a lesser number of men, perhaps because of the higher status of the male, have lived and acted as women. Even in the most restrictive societies there are periods in which temporary gender switches are tolerated if not encouraged, such as Halloween or Mardi Gras, and various initiation and transition festivals.

The more scholars examined the gender boxes to which people were assigned with their rigid classifications of what was masculine and what was feminine, the more it seemed to contradict the reality of human existence and behavior. Feminists, for example, emphasized that biology is not destiny and that the female can do almost anything a male can except manufacture and deliver sperm. Similarly a male can do almost anything a female can except ovulate, menstruate, gestate, and lactate, all activities associated with childbirth. Males, for their part, generally are larger than females, while females have more body fat and are less likely to build muscles than males, but there are tremendous individual variations. Both male and female characteristics can be plotted on two bell-shaped curves. While at the extreme end of the two curves, a small minority of males are found at one end and a small minor­ity of females at the other, there is large overlap of the two curves at almost every point.

Males can be sympathetic, caring, and supportive, while females can be aggressive, demanding, and self-centered. Both sexes can be nurturing to each other, although some individuals are more so than others. Some people can express this opposite gender side of themselves more openly than others, while some can only do so when they are cross-dressed or fantasizing them­selves in a different sex or gender role.

Much of what I have said is probably obvious to those who have stopped to observe human behavior, but in our western culture, as distinct from some others, it has been diffi­cult to acknowledge. Clinical literature in fact has been colored by the fact that those presenting for and accepted for treatment generally tend to be dysfunctional or under pressure to change, and it was these cases which were used by some professionals to build up a theory of transgendered behavior that psychopathology. Part of the difficulty as well, however, is that the field is such a fast-breaking one that much of society is caught in the preconceptions of earlier generations.

This is the great value of Dallas Denny’s bibliography. It emphasizes the most recent findings and how they compare with our presumptions of even less than 20 years ago. The literature in the field has escalated rapidly. In 1976 I included a 550-item bibliography of what I called transvestism and transsexualism as a supplement to a bibliography on homosexu­ality in order to emphasize to its users that this was different from homosexuality, something that not everyone accepted at the time (Bullough et al., 1976). But what could then be con­densed to the nature of a supplement now needs the kind of comprehensive volume that Dallas Denny has given us. Denny is in the forefront of those who are striving to bring about a better understanding of transgenderism, and her comments, though sometimes critical and brief, indicate just how far the field has progressed. It is the best guide to what has taken place in the field and will be indispensable not only to libraries and to scholars but perhaps even more importantly to those individuals who want to understand themselves and what is happening to increase our understanding of cross-dressing and transgender behavior.

Source: Dallas Denny. (1994). Introduction. In Gender dysphoria: A guide to research, pp. xxi-xxxviii. New York: Garland Publishers.

Gender dysphoria is a sense of inappropriateness about one’s assigned sex and the associated gender role. In its most commonly recognized form, transsexualism, it can be defined as a pervasive and persistent discomfort with one’s anatomic sex, with a concomitant desire to be rid of the primary and secondary sex characteristics and to replace them with those of the other sex. The Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, of the American Psychiatric Association (DSM III-R, 1987), which groups transsexualism and related conditions into a category known as the Gender Identity Disorders, notes that the essential feature “is an incongruence between assigned sex (i.e., the sex that is recorded on the birth certificate) and gender identity. Gender identity is the sense of knowing to which sex one belongs; that is, the awareness that ‘I am a male,’ or ‘I am a female.’ Gender identity is the private experience of gender role, and gender role is the public expression of gender identity. Gender role can be defined as everything that one says and does to indicate to others or to oneself the degree to which one is male or female” (p. 71). DSM III-R diagnostic criteria for Gender Identity Disorder of Childhood, Transsexualism, and Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) are given in Tables I-III.

 Table I

DSM III-R Diagnostic Criteria for

302.60 Gender Identity Disorder of Childhood

For females:

A. Persistent and intense distress about being a girl, and a stated desire to be a boy (not merely for any perceived cultural advantages from being a boy), or insistence that she is a boy.

B. Either (1) or (2):

(1) persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g. boys’ underwear and other accessories.

(2) persistent repudiation of female anatomic structures, as evidenced by at least one of the following:

(a) an assertion that she has, or will grow, a penis

(b) rejection of urinating in a sitting position

(c) assertion that she does not want to grow breasts or menstruate

C. The girl has not yet reached puberty.

 

For males:

A. Persistent and intense distress about being a boy and an intense desire to be a girl, or, more rarely, insistence that he is a girl.

B. Either (1) or (2):

(1) preoccupation with female stereotypical activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of male stereotypical toys, games, and activities

(2) persistent repudiation of male anatomic structures, as indicated by at least one of the following repeated assertions:

(a) that he will grow up to become a woman (not merely in role)

(b) that his penis or testes are disgusting or will disappear

(c) that it would be better not to have a penis or testes

C. The boy has not yet reached puberty.

—pp. 73-74, The Diagnostic and Statistical Manual of Mental Disorders, Volume III, Revised (DSM III-R).

 Table II

DSM III-R Diagnostic Criteria for 302.50 Transsexualism

A. Persistent discomfort and sense of inappropriateness about one’s assigned sex.

B. Persistent preoccupation for at least two years with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.

C. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

—p. 76, The Diagnostic and Statistical Manual of Mental Disorders, Volume III, Revised (DSM III-R).

Table III

DSM III-R Diagnostic Criteria for 302.85 Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT)

A. Persistent or recurrent discomfort and sense of inappropriateness about one’s assigned sex.

B. Persistent or recurrent cross-dressing in the role of the other sex, either in fantasy or actuality, but not for the purpose of sexual excitement (as in Transvestic Fetishism).

C. No persistent preoccupation (for at least two years) with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex (as in Transsexualism).

D. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

—p. 77, The Diagnostic and Statistical Manual of Mental Disorders, Volume III, Revised (DSM III-R).

When gender dysphoria occurs after puberty, persists unabated for more than two years, and when there is a desire to be rid of both primary and secondary and sexual characteristics (e.g., to have hormonal therapy and genital sex reassignment surgery), and when crossdressing or thoughts of crossdressing do not produce sexual arousal, the individual meets the diagnostic criteria for Transsexualism. Those who have not yet reached puberty are assigned Gender Identity Disorder of Childhood, and those who do not meet the two-year limit are assigned Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT). Those who are gender dysphoric and experience sexual arousal are assigned to the garbage category Gender Identity Disorder, Not Otherwise Specified (GIDNOS).

There is a growing awareness by clinicians that some of the “truisms” about transsexualism in the literature are perpetuations of mistaken initial impressions and do not present an accurate picture of those requesting sex reassignment. For instance, as many as 50% of males who were previously heterosexual and who request sex reassignment report sexual arousal when crossdressing (Bradley et al., 1991). Proposed DSM IV diagnostic criteria would remove the present focus on genital modification and would not exclude hormonal and surgical treatment for those who experience sexual arousal on crossdressing (Bradley et al., 1991). Although the popular notion of “sex change” presupposes genital modification, in truth, many transgendered persons (i.e., persons with gender dysphoria) are content to live as members of the other sex and have no desire for surgery (Bockting & Coleman, in press; Bolin, in preparation; Boswell, 1991).

Gender dysphoria occurs in people of both sexes and all ages, and has been documented throughout the world since ancient times (Ackroyd, 1979; Bullough, 1975, 1976; Bullough & Bullough, 1993; Buhrich, 1977; Green, 1966, 1969). Many non-Western cultures have institutionalized social roles for transgendered persons (cf. Ackroyd, 1979; Bullough, 1976; Bullough & Bullough, 1993; Ford & Beach, 1951; Williams, 1986), but Western societies have a dichotomous division of sex. One can be male, or one can be female. Any variation from the rank and file, whether physical or psychological, has historically resulted in stigmatization and devaluation of the person who is “different.” This holds for any sort of identifiable trait or set of traits (cf. Goffman, 1963), for instance, mental retardation (Dennis, unpublished; Wolfensberger, 1987), but an atypical gender presentation can be particularly stigmatizing, especially for males (Green, 1974).

The medical community’s conception that a gender identity which varies from the norm is pathological is largely a function of the application of Western medical thinking to what is undoubtedly a normal human variation—just as has occurred with variant forms of sexual expression (cf. Bullough & Bullough, 1993, ch. 9; Smith, 1991; Whittle, 1993)—and has resulted in the pathologization of gender dysphoria—witness the very term. The individual is seen as “ill,” whether or not medical treatment is desired or indicated (Bullough & Bullough, 1993). This was the case with homosexuality, also, which was classified as a mental disorder from the 19th century until its removal from the DSM III in 1980 (Smith, 1992a). Incidentally, the demedicalization of homosexuality was strongly resisted by factions within the American Psychiatric Association, and it was political considerations, rather than any consensus among psychiatrists, which resulted in its removal from the DSM (DSM III, 1980; Smith, 1992b).

Unlike homosexuality, which does not routinely require medical intervention, the hormonal and surgical treatment of transsexualism requires the complicity of medical professionals. The desire of transsexual people for bodily alterations (and the necessity to have such alterations if they are to pass successfully as a member of the other sex) leads them to seek not only hormonal therapy (and for male-to-female persons, electrolysis), but various surgical procedures including but not limited to orchidectomy, vaginoplasty, breast augmentation, rhinoplasty, and laryngeal reduction for male-to-female persons, and metadoioplasty (genitoplasty), phalloplasty, breast reduction, chest wall reconstruction, hysterectomy, oophorectomy, and salpingectomy for female-to-male persons (Clemmensen, 1990; Dickey & Steiner, 1990).

Medicine, which until this century had little or no experience in dealing with persons who requested intrusive medical treatments on healthy tissue, has grappled, as it has with plastic surgery, with the ethics of such treatment (cf Brown, 1988; Edgerton, 1984; Kubie & Mackie, 1968; Lothstein, 1982; Walters, 1986). Unlike plastic surgery patients, however, those who wish to bring their secondary and primary sexual characteristics into consonance with their sense of self [the fulfillment of which wish has been called, in a rather hostile manner, “psychosurgery” (Kavanaugh & Volkan, 1979)], have been repeatedly characterized as pathological, and have in fact been much maligned in the supposedly objective scientific literature (cf Cappon, 1970; Kavanaugh & Volkan, 1979; Kirkham & Sagarin, 1969; Lothstein, 1983; McHugh, 1992; Meerloo, 1967; Michaud & Bold, 1979; Ostow, 1953; Raymond, 1979; Socarides, 1969, 1970, 1976, 1977; Stoller, 1982; Szasz, 1980). Baker (1969) concluded that there was a great deal of “psychiatric name-calling” in the literature of transsexualism. Nonetheless, transsexual persons have for the most part been willing and even eager to accept and even demand “medical colonization” (Bolin, 1985) in order to obtain treatment (cf. Hamburger, 1953).

The number of persons with gender dysphoria is not known. Estimates of population rates have been made on the basis of those presenting for sex reassignment (cf. Hoenig & Kenna, 1973), and have been periodically revised upward, but many transgendered persons do not come to the attention of the medical community, escaping this medical census. The DSM III-R gives an incidence rate for transsexualism of 1:30,000 for males and 1:100,000 for females, but the true rates are bound to be much higher. There is a cascade effect; as more services develop, more men and women come forward, seeking sex reassignment.

Most persons diagnosable as transsexual do not, for one reason or another, ever request sex reassignment (Blanchard, 1990). Many—in fact, most—remain for one reason or another in the gender of original assignment. Some pursue gender congruency in an extra-medical fashion, obtaining hormones and sometimes surgical procedures from black market sources. Some take an “a la carte” approach, choosing caregivers as they might for any other condition which perturbed them. Only a minority go to gender clinics—and it is from applications to gender clinics that incidence rates have been calculated.

The recent explosion of the “transgender community,” a conglomeration of support groups, information clearinghouses, advocacy organizations, political action committees, publishers, telephone help lines, and computer bulletin boards (Bockting & Coleman, in preparation) suggests that the DSM III-R estimates are off by at least an order of magnitude. Many of these grassroots organizations are hard-pressed to keep up with the numerous phone calls and letters they get from persons with gender dysphoria. The closeted nature of most transgendered persons may make accurate estimates impossible, but one thing is certain: gender dysphoria can no longer be considered uncommon.

The causes of gender dysphoria are unknown but hotly debated. Biological, familial, and psychodynamic theories have been advanced and discounted (cf Bullough & Bullough, 1993; Hoenig, 1981, 1985a, 1985b). Methods of treatment have been even more in dispute, with some parties (often those who have had no or at best limited contact with persons with gender dysphoria and usually psychiatrists; see McHugh, 1992, for the usual argument) claiming that psychotherapy, and not surgery, is the proper method of treatment for a psychological condition, while others argue that genital surgery is palliative and even necessary in some cases (cf. Benjamin, 1966; Money, 1971). Some clinicians believe that surgery should be permitted only in special circumstances (Lothstein, 1982; Stoller, 1969a, 1982). There has been at least one documented instance of bad science done in an effort to prove a political point; Meyer & Reter’s 1979 paper has been roundly criticized, most effectively, in my opinion, by Blanchard & Sheridan (1990). (1)

There is disagreement about the effectiveness of various methods of treatment; assessment of the outcome of genital surgery, for example, is made difficult by the well-known propensity of operated individuals to be lost to follow-up (Lothstein, 1982). It is not surprising that members of a highly stigmatized minority would, when given the chance, disappear into the mainstream of society, but transsexual persons have been much maligned for doing so. This disappearance is probably the greatest single indicator of the success of surgical treatment, as most post-operative men and women apparently successfully integrate themselves into society—but we cannot be sure. The majority of outcome studies have shown high satisfaction rates with surgical treatment (see Blanchard & Sheridan, 1990, for a recent summary), although Lothstein (1982) and Lothstein and Brown (1992) caution that the findings of other authors may be overoptimistic.

As measured from the date of Christine Jorgensen’s 1953 return to the United States following surgical and hormonal sex reassignment in Denmark, gender dysphoria (a term first used by Norman Fisk nearly two decades later) is forty years old. As clinicians have discovered more about gender dysphoria, and as persons with gender dysphoria have begun to demand their right to treatment, conditions have improved. 1979 saw the publication of the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc., an organization comprised of concerned psychologists, physicians, and other caregivers [Walker et al., 1984; see Appendix I for the latest (1990) revision]. The Standards of Care are minimum voluntary (2) guidelines for the hormonal and surgical treatment of transsexual persons; as such, they were an important step in the assurance of competent care. Clinicians have slowly come to realize (often educated by transgendered persons themselves; see Pauly’s 1991 discussion of Lou Sullivan) that transsexual persons come in all shapes and sizes—that they are not necessarily the “most feminine of males” (as Stoller believed and others still believe; see Stoller 1969b; Dolan, 1987); that transsexualism is not predicated on a prior gay or a postsurgical heterosexual orientation (this was pointed out as early as 1974; cf. Barr et al., 1974); and that female-to-male gender dysphoria may be as common as male-to-female gender dysphoria (Godlewski, 1988; Gooren, 1989). Most importantly, both persons with gender dysphoria and caregivers are coming to realize that genital surgery is not the be-all and end-all for all persons with gender dysphoria. Those who did not profess to want surgery in the early years were often denied hormonal treatment (3). Now we are beginning to understand that it is possible for an individual to live a fulfilling and productive life as a member of the sex opposite that given at birth without surgical manipulation (see Bockting & Coleman, in preparation; Bolin, in preparation; Boswell, 1991; and Bullough & Bullough, 1993, p. 268, for examples of this new sensibility) (4).

Research on gender dysphoria has usually centered on clinical issues. I have pointed out elsewhere (Denny, 1992; discussed in Bullough & Bullough, 1993, p. 268) that the selection criteria of the university-based gender clinics (which saw themselves as experimental centers) resulted in a skewed picture of transsexual persons, with those who were accepted for treatment (i.e., those who best fulfilled the stereotypes) being used to define the condition. Consequently, there are a number of reports in which transsexual persons are characterized as having a great deal of psychopathology in addition to their gender dysphoria (cf Stone, 1991). Such characterization of the personality traits and lifestyles of transgendered persons is sometimes indistinguishable from name-calling; it is in such contexts that countertransference is most obvious. (5) The bizarre appearance, problematic lifestyles, and personality and behavioral disturbances noted by some clinicians in the majority of their transsexual patients have not been validated in common-sense approaches such as Bolin’s (1988) study, and many present-day researchers have not noted psychopathology significantly greater than that of the general population—although others have (see Bolin, 1988, and Stone, 1991, for examples of opposing views).

Now that transsexualism (as measured from Jorgensen’s return from Copenhagen) has reached the age of 40, sex reassignment no longer seems as bizarre and controversial as it once did, whether to the lay public, or to caregivers, or to transgendered persons themselves. Most Americans have been touched in some way by transsexualism, whether at home, at church, or in the workplace. Caregivers have learned much about the nature of gender dysphoria, and consumers with gender dysphoria have lost their timidity and are demanding fair treatment in all arenas—social, vocational, legal, and medical. The balance of power, which gave the university-based gender clinics of the 1960s and 1970s undue control over the lives and destinies of transsexual persons, is swinging toward equilibrium—in fact, may have already swung past the balance point, with hormonal and surgical procedures now being too easy to obtain. A new generation of researchers, clinicians, and consumers will find equilibrium. The literature will provide the tools with which to do that. This bibliography represents that literature, imperfect as it is.

Source: Dallas Denny. (1994). Afterword. In Gender dysphoria: A guide to research, pp. 551-554. New York: Garland Publishers.

Despite tremendous advances and many well-written, methodologically sound papers, there is much to criticize in the literature. Studies tend to suffer from the usual problems of applied research. Numbers of subjects are small, and intervening conditions and variables are rarely controlled or even identified. Studies have not been carried out under blind conditions (that is, with the data collectors being ignorant of the hypotheses of the research or assignment of subjects to treatment or control groups). Group studies are rare, and, when they do exist, have sometimes collapsed individual case studies rather than forming a true group. Authors of early outcome studies, in particular, were guilty of this; this resulted in the same subjects being used in various studies. There is rarely extensive follow-up of treatment (and transsexual people, rather than researchers, are still being blamed for this). Most studies have been retrospective rather than prospective. Longitudinal studies have been very rare; Richard Green’s is a notable exception. Group studies using controls are especially rare, and single-subject, repeated measures studies are almost nonexistent.

There are difficulties other than with reliability. Problems of validity have been rampant. Most studies have a clinical bias, viewing the transgendered individual in a specialized and highly artificial situation. This skews the subject population, as only those seeking “help” show up and are studied in conditions which are quite unlike those in which they normally function. Researchers, with the exception of Bolin, have been for the most part blind to the way their own needs and prejudices influence the treatment setting and have been quick to place the blame for methodological problems on their transgendered clientele.

The individual and vocational biases of authors tend to be reflected in their work. Psychoanalysts, for example, have been the most vocal opponents of surgical treatment of transgendered people (perhaps because they have contributed the least to understanding and treating them). Lack of specialized training programs in human sexuality in general and gender dysphoria in particular has doubtless had an impact on the quality of the research questions asked by researchers of all theoretical orientations.

A Prescription for the Future

Transsexual people are not particularly common and are not particularly cooperative when they are denied their way—and many never make it to the treatment setting. This makes the already considerable problem of doing group studies in applied settings even more difficult. Certainly, group studies are needed, but they must be more rigorous than those which have gone before. Poorly-designed studies were better than nothing when there was no literature of gender dysphoria, but now there is a literature of gender dysphoria. The time for sloppy work is past. Future studies must replicate, confirming or not confirming already existing studies as well as breaking new ground. The definitive outcome study, for example, has yet to be done and replicated—and until that happens—until the problem of the “disappearance” into society of postoperative transsexual persons is solved—no one will really know how effective the surgical treatment of transsexualism is.

Single-subject studies, using the methodology of applied behavior analysis (cf Barlow, Abel, & Blanchard, 1979; and Barlow, Reynolds, & Agras, 1973), are quite as rigorous and scientifically convincing as group studies (some would say more so) and would be much easier to do, and yet they remain rare. They can tell us much. Systematic replication of such studies would build the knowledge base in a rapid manner, just as such studies quickly yielded a reliable and valid technology of controlling persons with severe behavioral pathology. More should be done.

The publication in 1978 of Kessler & McKenna’s Gender: An Ethnomethodological Approach, and Anne Bolin’s In Search of Eve: Transsexual Rites of Passage a decade later was of great import, for they had fresh (and much-needed) viewpoints that have gone unnoticed or at least largely uncommented on in the clinical literature. Kessler & McKenna’s theory of gender drew heavily upon their observations of transsexual persons. Both they and Bolin studied transsexual people in context, in their natural settings, rather than in the highly artificial setting of a physician’s office or a gender clinic. Bolin, in no uncertain terms, pointed out the major flaw in the literature—its almost exclusive reliance on clinical reports.

For centuries, biologists observed and collected and categorized their subjects. Only after a rigorous period of classification did they start in any great measure to theorize. Psychologists, on the other hand, began to theorize without bothering to assemble such a knowledge base. Consequently, biological theories such as Charles Darwin’s and Alfred Russel Wallace’s theory of natural selection have withstood the test of time, while entire schools of psychology (for example, the Hullian) have withered and disappeared, leaving no legacy.

Researchers in the field of gender dysphoria should follow in the steps of the biologists and take the time to learn what transsexual people are like before soaring off into the delirious heights of theory. We should avoid the bad precedence of mainstream American psychology. If we do so, we will build something that will endure. If we do not, then our work will be lost.