Volume 2, Number 1, January - March 1998
Psychological and Social Function Before and After Phalloplasty
By James Barrett
Citation: Barrett J.(1998) Psychological and Social Function Before and After Phalloplasty. IJT 2,1, http://www.symposion.com/ijt/ijtc0301.htm
There are no quantitative assessments of the benefits of phalloplasty in a female transsexual population. The study addresses this question, comparing transsexuals accepted for such surgery with transsexuals after such surgery has been performed.
A population of 23 transsexuals accepted for phalloplasty was compared to a population of 40 who had undergone such surgery between six and one hundred and sixty months previously. The General Health Questionnaire (GHQ), Symptom Checklist 90 (SCL-90), Bem Sex Role Inventory and Social Role Performance Schedule (SRPS) were employed. Additionally, a questionnaire assessing satisfaction with cosmetic appearance, sexual function, relationship and urinary function was used, along with a semi-structured interview quantifying alcohol, cigarette and drug usage, and current sexual practice.
There were significant differences between the populations. The post operative group showed higher depression ratings on the depression subscale of the GHQ. The masculine pre-operative Bem scores were neutral post-operatively as feminine sub-scores increased. There was improved satisfaction with genital appearance post-operatively, but satisfaction with relationships fell, although to a non-significant extent. Most other changes were in the expected direction but did not achieve significance.
Transsexuals accepted for phalloplasty have very good psychological health. Tendency to further improvement is the case after phalloplasty. Depression is commoner, however, and quality of relationships declines somewhat, perhaps in consequence. Surgeons might advise partners as well as patients of realistic expectations from such surgery.
Transsexuals are subjected to close psychiatric supervision to determine whether their social, sexual, psychological and employment status remains stable. State sector services are heavily concentrated in the south east of England, with the largest center being at the Charing Cross Hospital Department of Psychiatry.
|The Charing Cross Gender Identity Clinic, which operates according to the Harry
Benjamin International Gender Dysphoria Association criteria, receives about four hundred
referrals yearly. These come from regional psychiatric services who have obtained
permission for an extra-contractual referral and in addition directly from General
Practitioner Fundholding Practices. Referrals are subject to a waiting time that has
varied over the years from between three and nine months. New patients are seen for at
least one hour by an experienced interviewer who elicits a full psychiatric history with
particular emphasis on childhood gender-stereotypic or reverse stereotypic behavior, the
rate at which these progressed, and subsequent personality and sexual development. This
information is elicited again at a second hour long interview with a different member of
the clinic staff, not less than three months later, and is usually also collaborated by
interviews with parents, conducted with the consent of patients. In the event of the
second interview producing an opinion that a patient seems to be reasonably
straightforward transsexual, and no medical contra-indication exists, treatment with
cross-sexed hormones would be commenced, usually starting at a low dose, and in
conjunction with advice to General Practitioners concerning the monitoring of liver
function tests, blood pressure, and lipid profile.
Follow-up appointments are conducted at about three-monthly intervals at which assessments are made of patients social, employment, sexual and psychological stability. Confirmation of employment is sought (with patient consent) from employers. Physical changes with commencement of hormone treatment are monitored, as are alterations in transsexual drive as time passes and a greater amount and quality of attention are given to such drive by both patient and family. Patients are required to change their name by deed poll rather than informally, and are very strongly encouraged to divorce their spouse if they no longer intend to live with them. Partners, family and friends may be interviewed, and patients are offered the chance to join psychotherapy groups on a monthly basis in one of three groups depending on degree of psychological sophistication and ego-strength.
Patients who demonstrate long-term stability under such high levels of scrutiny, and who remain stable for at least two years, at least one year of which has been in full-time occupation (as proved by pay slips, etc.) are accepted as being suitable candidates for gender reassignment surgery. The National Health Service waiting list for gender reassignment surgery is about three years long.
Sensation in a neophallus depends upon a nervous supply and is important to prevent the damage which might otherwise befall insensate tissue. Some surgeons employ co-option of adjacent nerves, such as the pudenal nerve, into the neophallus whilst others attempt to preserve the nerve of the clitoris and divert it into the shaft of the neophallus. Still others attempt to preserve the entire clitoris and incorporate it into a rolled skin tube neophallus.
Obtaining sufficient tissue to create a neophallus or neoscrotum may also pose problems. Some surgeons use tissue from co-incidental vulvectomy or mastectomy, which may have been previously enlarged with subcutaneous tissue expanders (Sengezer M, Sadove RC, 1993) whilst others use such tissue expanders in the upper arm or leg to create areas of skin that may be used as material for autologous transplantation.
Sørensen (1981) reported a study that distinguished the outcome in two patients who had undergone phalloplasty from five who had not. One of these two had previously explicitly been refused consent for phalloplasty by psychiatrists (obtaining it illicitly in the private sector). The other was reported to be unhappy with the technical outcome of the surgery, but no more objective attempt to outline either patient's psychological or social functioning appeared to have been made.
Tsoi (1980, 1992, 1993) studied male and female transsexuals in Singapore (these terms relating to birth sex). Following up both the female and male patients between two to five years after gender reassignment surgery, Tsoi found that female patients had more stable partner relationships than males (81% compared to 67%) although there was no difference between sexes of transsexuals in overall outcome. He noted that only 39% of female transsexuals were satisfied with the results of their phalloplasty, as compared with the 91% of male patients who were satisfied with a vaginoplasty. His studies have been more concerned with comparing male to female transsexuals than with investigating the effects of intervention versus non-intervention in either sex.
Kockett and Fahrner (1988) interviewed 37 male and 21 female transsexuals an average of 5.5 years after diagnosis. Considering those who had experienced surgery, the two sexes did report equivalent levels of sexual and relationship satisfaction post surgically, and were similarly socially integrated. Unfortunately it is not made clear in their paper what kind of surgery was involved, and whether any of the female patients had undergone phalloplasty.
Pauly (1981) reviewed world literature concerning the outcome of sex-reassignment for both male and female transsexuals, quoting evidence presented at conference by Pierce et al. who found that 20 out of 22 female transsexuals undergoing phalloplasty did well, and only one regretted undergoing the procedure. He quotes also Lothstein, who spoke at the same conference, and found that whilst all the female transsexuals undergoing phalloplasty were satisfied with the surgical results and two-thirds of patients reported improved sex lives, half "entertained suicidal ideation" and two "wished their penises were larger and worried whether they could ever satisfy a woman". Lothstein is reported as finding that these patients showed some improvement on some measures of social and psychological functioning
Reviewing world literature, Lundström, Pauly and Wålinder (1984) concluded that 10% of patients have an unsuccessful result from gender reassignment surgery. Successful outcome was thought to be commoner in females, although not significantly so. Satisfactory surgical outcome was found to be a fair predictor of overall outcome, although other variables were important. Outcome was thought to be inversely related to age, and this was thought to be mediated by the proportion of secondary to core patients. Secondary transsexual patients not recommended for gender reassignment surgery by their psychiatrists were thought to fare better than primary patients so treated. Lundström et al concluded that surgery should be offered to core transsexual patients only, with caution being particularly applied in the appraisals of those over 30 and with unstable histories Their review did not distinguish between phalloplasty and other surgical procedures such as mastectomy and bilateral salpingo-oophorectomy, and did not make it clear in all cases what degree of psychological supervision (if any) had preceded phalloplasty.
The null hypothesis being tested is that there is no difference between a group of female transsexuals who have undergone phalloplasty and a group who have been accepted for and are waiting to undergo phalloplasty regarding the following major measures:
One possible confounding factor was that the post-op population may well be a "positive" or "negative"selection of the entire postoperative population. This may confound in two ways. Those patients who never attend for follow-up post-op might be severely mentally ill or might have killed themselves. Equally they might have achieved their lifelong aim of becoming ordinary men and consequently have not wanted to talk to the doctors who remind them of an origin they would rather forget. The percentage of responders was 100% of those asked. This surprisingly high figure was felt to be a consequence of there being little else to do whilst waiting in an out-patient department and also of the patient group seeing response as vital to help others who might in the future be in the same position as they.
The pubic phalloplasty method had been used in all patients. The neophallus had been constructed from lower abdominal and suprapubic skin, and contained within it a neourethra constructed from pedicled right labial tissue. Clitoral tissue with its associated nerves had been incorporated into the neourethra, with the glans clitoris projecting into the lumen of the neourethra to avoid trapped secretions leading to cyst formation
The population of transsexuals waiting to undergo phalloplasty was drawn from two sources. Some were patients attending the Gender Identity Clinic at Charing Cross Hospital who had been diagnosed as female to male transsexuals and stabilized on hormone therapy for not less than one year, and who were advanced to the department of urological surgery as candidates for gender reassignment surgery. Others were seen at the department of urological surgery when they presented for a pre-phalloplasty work-up. There were no demographic differences in these groups other than age being slightly higher in the second group.
The post-phalloplasty group consisted only of those who were engaged in follow-up at the surgical clinic. This represented about three quarters of those upon whom he had operated. It was unclear whether these individuals were different from the quarter who were lost to follow-up. It might have been argued that those who were lost to follow-up were functioning so poorly as to be unable to attend follow-up, or so disillusioned that they no longer attended. Equally, it might have been argued that those who were lost to follow-up had achieved their life-long goal of attaining normal masculinity, and had blended in with the ordinary male population as they had always wanted to do. If this was the case, it might have been that those who continued to attend for follow-up were those whose surgical procedures had not been effective at ameliorating their psychological distress.
It was explained to all patients that the purpose of the study was to compare the psychological and social function of a group of individuals who had experienced phalloplasty with a group who were waiting to experience phalloplasty.
It was made clear that co-operation in this project was entirely voluntary and would not in any way affect treatment. The interviewer was not considered part of the urological team treating the patient. It was made very clear that he was a psychiatrist and not a surgeon, and that he would not mind if patients criticized surgeons and the results of surgery. It was made clear that the answers patients gave would never be revealed to the surgeons except as statistical tables, such that their particular answers could not be identified. Finally, the fact that the views of surgery or surgeons are not universally positive suggests that the bias has been excluded.
The populations were studied using a combination of structured interview and self-report questionnaire. Three self-report measures were used.
The first instrument used was the General Health Questionnaire. The second was the Symptom Checklist 90. The Symptom Checklist 90 subscale for somatization was omitted because it was felt that since one population was being interviewed just prior to a surgical appointment and part of the other in a setting far removed from surgical considerations a distinction might emerge between the two populations which was related to setting rather than symptomatology. The omission of the somatization subscale from the SCL90 implies the scale not being used quite as was intended, but guidelines for the use of the scale indicate that up to 25% of the questions can be omitted before the use of the instrument is seriously compromised.
The third instrument employed was the Bem Sex Role Inventory, a fairly well validated measure of masculine and feminine traits. The Bem Sex Role Inventory has been widely used to assess masculinity and femininity but was validated using the USA population, rather than the UK population it had been applied to in this study. The two populations are probably sufficiently culturally similar to render its use valid.
All three of these instruments were completed by patients in their own home after they had been interviewed by the researcher, and returned in a stamped envelope.
Two structured interview instruments were employed: the first was the Social Role Performance Schedule. This gives a sensitive measure of social role function in normal individuals. The Social Role Performance Schedule was developed for use in marginally impaired psychiatric populations. If the Social Role Performance Schedule is less accurate at the extremes of its scale, differences between the populations might be obscured.
The second structured interview instrument was developed for this study and recorded demographic details, past and present employment and incomes, previous psychiatric history and acts of self-harm, current physical status, current and previous relationships, pregnancies and sexuality, prescribed and non-prescribed drug use, and rated satisfaction with genital appearance, urinary, sexual and relationship functioning on five point rating scales. In addition questions were asked which were not amenable to rating scale type assessment concerning satisfaction with service provision and effects of surgery.
Patients were interviewed and the two structured interview instruments administered in the Gender Identity Clinic, the surgical clinic, or (in five cases) in their home over the telephone. The patients were sent within five days thereafter the three self-report questionnaires, along with a pre-paid and addressed reply envelope.
Results were analyzed using the Statistical Package for the Social Sciences software, comparison of means being made by T-test.
General health Questionnaire As shown below, regarding the General Health Questionnaire there was no significant difference between the populations, with all subscales save subscale D (depression) showing higher figures in the post-operative group.
Table 1: GHQ Scores
Symptom Checklist 90
Table 2: Sympton Checklist 90 scores
Bem Sex Role Inventory
The fully scaled score gives a value between 0 and 100, where 50 is neuter. Scores below 50 indicate masculine attributes in inverse proportion to the score. Scores above 50 indicate feminine attributes in proportion to the score.
As shown below, regarding the Bem Sex Role Inventory, the post-operative population showed a significantly higher female subscale score, which lead to the fully scaled score for the post-operative population being androgynous, and significantly different from the rather masculine score of the pre-operative population.
Table 3: BEM sex-role inventory scores
Social Role Performance Schedule
So few patients in either population had responsibility for child care that it was not possible to compare the abilities of the two populations in this regard.
Table 4: Social role performance schedule scores
Employment, income; alcohol and cigarette use
There was no significant difference in the income of the populations, although mean income of those who were employed was higher in the post-operative population.
There was no significant difference in the alcohol and cigarette use between the populations.
Table 5: Alcohol and cigarette use
Genital appearance, urinary and sexual function, relationship
As shown below, regarding genital appearance the post-operative population is significantly more satisfied than the pre-operative population.
Regarding sexual and urinary function, there were no significant differences between the pre-operative and post-operative populations, although the post-operative population showed a higher mean satisfaction score.
Regarding current relationship, there was no significant difference between the pre-operative and post-operative populations, although the post-operative population showed a lower mean satisfaction score.
Table 6: Satisfaction with genital appearance, sexual function, urinary function and current relationship.
Because of the small numbers involved in this study the power was low. Only differences between the populations of greater than 20% had a greater than 80% chance of being detected by this study.
An attempt was made to investigate whether any difference was found between the 6 months postoperative patients and the many years postoperative patients. The improved scores on SCL90 were sustained and improved over time, but dividing the sample lead to such reduced sample size per group that the power calculations showed that any continued improvement would have to be massive in order to show significance in the smaller groups.
Sources of error
Although no significant difference was found between the groups regarding the main outcome measure (Symptom Checklist 90), differences in many other measures approached conventional levels of significance. This suggests that type 2 errors in these measures are not unlikely. Had there been greater numbers of subjects in each population it is possible that a significant improvement in post-operative psychological functioning might have been seen. It is particularly interesting that the level of satisfaction with current relationship should have fallen post-operatively, and had greater numbers been used, this also might have been to a significant extent.
Change in Bem Sex Role Inventory score
Pauly (1981) quotes evidence presented at conference by Pierce et al. who found that 20 out of 22 female transsexuals undergoing phalloplasty did well, and only one regretted undergoing the procedure. He quotes also Lothstein, who spoke at the same conference, and found that whilst all the female transsexuals undergoing phalloplasty were satisfied with the surgical results and two-thirds of patients reported improved sex lives, half "entertained suicidal ideation" and two "wished their penises were larger and worried whether they could ever satisfy a woman". Lothstein is reported as finding that these patients improved on some measures of social and psychological functioning. The results of this study seem more in keeping with those of Pierce than of Lothstein, and certainly no patient in the post-operative group reported suicidal ideation.
Comparison to male transsexuals
Hunt and Hampson (1980) following up male transsexuals for at least 6 years reported "no changes in levels of psychopathology and only modest gains overall in economic functioning and interpersonal relationships" after sex reassignment. This would seem in keeping with the findings of this study, although if anything, a slight trend for interpersonal relationships to worsen was noted here.
Lindemalm, Körlin and Uddnberg (1986) reported a follow-up of 13 transsexual males for at least 6 years. They also reported a modest improvement in mental health but no general improvement in the social situation after sex reassignment. This also seems to resonate with this study.
Theoretical implications of this study
Practical implications of this study
An unexpected finding is that quality of relationships seems to fall after phalloplasty, albeit to a non-significant extent. This might be because of partners of patients being sexually disappointed, having had unrealistic expectations of such surgery. They might have expected an ability to have sexual intercourse without the use of prostheses where this was previously impossible. Patients, having been carefully counseled by the surgeon, might have had expectations more in keeping with what is possible, have been expecting less, and so were not disappointed. Whilst this idea would require further studies to be supported, this study implies that it would be as well for surgeons to at least consult with partners of patient as well as patients themselves, to prevent unrealistic expectations being developed by partners.
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Harry Benjamin International Gender Dysphoria Association inc. 1300 South 2nd Street Suite 180 Minneapolis MN 55454 USA
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Acknowledgments. I would like to acknowledge the help of Mr. John Pryor, the advice of Dr. D.H. Montgomery and Prof. R. Green, and the assistance of the patients without whom the study would not have been possible.