"Twelve transsexuals"- A psychiatric appraisal of twelve patients seeking sex change surgeryDR Doongaji1, AS Sheth1, JS Apte1, MPE Bharucha1, M Dattatreyulu1, CB Khare1, PD Lakdawala1, SP Ratnaparkhi1, KI Bendale1, Shubha S Thatte1, Mala Rao1, MH Keswani2
1 Department of Psychiatry, Seth G. S. Medical College and K.E.M. Hospital, Parel, Bombay 400012, India
2 Plastic Surgeon, Jaslok Hospital, Bombay, India
A clinical psychiatric study o f twelve patients seeking sex change surgery is presented. The demographic data, clinical characteristics and the results of psychological testing are described. Unlike as in the Western countries, males and females were equally distributed in the study sample. The diagnosis of true transsexualism could be made in six cases. The alternative diagnoses were schizophrenia and sexual deviation. The aetiology of transsexuality, its diagnostic criteria, the differential diagnosis and the associated medico-legal and ethical problems are pointed out
Very many years ago, a famous French politician stood up in the Parliament, and said that there was a great difference between men and women. Immediately, the house stood up as one man and cried: "Vive la Difference-Long Live the Difference!" It is a sign of the times that this vital difference between men and women may cease to exist, and that it will become more and more difficult to make a distinction between the two sexes on the basis of external appearances by the turn of this century.
Evidence from the anthropological literature indicates that transsexualism, as a syndrome is
Upto 1960 the literature consisted of sporadic case-reports. Subsequently reports from larger series appeared in the literature. 
In 1953, Hamburger analysed 465 letters from patients seeking help for this problem.  He showed that the letters came from all the five continents. In 1968 a serial analysis of 700 letters by Hoopes et al  from the Johns Hopkins Gender Identity Clinic demonstrated that the syndrome is widespread in the United States. In the same year Walinder  from Sweeden collected 110 cases from all over the country of which 43 cases were personally known to him. Steiner and Peitich  (1974) from the University of Toronto described their encouraging results on 88 transsexuals referred from across Canada.  Their pilot project began in 1968 and the research aimed at studying psychiatric, psychological, neuroendocrinological and social aspects of transsexualism. 
In India transsexuality has been given a wide berth by the medical community and the subject has gained prominence only during the last decade largely through the efforts of the lay press. So far only the surgical aspects of sex-change operations have been reported by Keswani.  There is no report on the psychiatric aspects of this condition from this country.
Abraham is said to have performed the first sex-change operation in 1931.  Subsequently the details of cases treated by plastic surgery have been reported by Huelke (1949),  Dukor (1951),  Fogh-Anderson (1956),  Hertz  (1961), Benjamin (1964)  and Pauly (1965). 
The recent glossary to the International Classification of Diseases redefines trans-sexuality as a non-psychotic disorder of sexual identity in its own right, and distinguishes it by a separate ICD diagnostic number 302.8. 
The diagnostic criteria for transsexualims are: 
This paper presents a psychiatric appraisal of 12 patients seeking surgery for gender transformation.
This study was conducted in the psychiatric department of the K.E.M. Hospital, Bombay. All the 12 subjects were referred for psychiatric assessment prior to surgery by a plastic surgeon. They were interviewed at length with the help of a structured proforma. The details of the interview were tape-recorded. Objective data from the family members was collected whenever possible. A complete physical examination and psychological testing (I.Q., MMPI, Rorschach and EPI) was done. Examination for endocrine abnormalities and genotyping was requested when it was thought necessary, viz., in those instances where the anatomical sex was ambiguous; or where the secondary sex characteristics had not yet developed (Case No. 6). The subjects were then discussed at departmental clinical meetings, and decisions about the psychiatric diagnosis and probable prognosis were conveyed to the referring surgeon.
The demographic data of the study sample is shown in [Table 1]. The males and females were almost equally represented. The female patients were masculine in appearance and in dress, while it was the other way round with the males in most of the cases.
A diagnosis of true transsexuality could be established in 6 subjects i.e. 50% of the patients, while the alternative diagnoses were schizophrenia in 4 patients and sexual deviation in 2 patients viz., homosexuality, transvestism and exhibitionism. The anatomical sex conformed with the assigned sex in all cases.
The conflict about gender identification was present before the age of 7 years in the true transsexuals whereas the onset was much later in most of the others [Table 2]. It was not possible to establish a firm correlationship between any particular phase of psycho-sexual development and the onset of the condition. In 3 cases the parent of the opposite sex had played a dominant role in the child's early life, in contrast to the parent of the same sex who was passive and ineffectual. There was no history of sexual trauma in childhood in any instance. All true transsexuals except one regularly indulged in sexual activity with a partner of the same anatomical sex. All of them denied that this implied any homosexual behaviour because of their fixed and firm belief that they belonged to the opposite sex. Most of the true transsexuals practised cross-dressing in privacy, and this was accompanied by a subjective feeling of relaxation rather than erotic excitement. One patient who was not a true transsexual described passive homosexual, transvestite and exhibitionistic practices to orgasm.
Attitudes of patient and family to sex change
The patients had become aware of a surgical treatment for the condition through the articles in lay press. Three of them had tried hormone therapy. [Table 3].
All patients looked forward to the proposed change of sex inspite of being aware of the possible complications and medico-legal problems. But there was parental and family resistance to the proposed sex change in all cases except one. This was a young girl of 14 years whose parents insistently requested surgery for her.
All were dissatisfied with their sexual identity, and felt repugnance towards their sexual organs. Two patients, both true transsexuals, had made attempts at self-mutilation.
When it was pointed out that the proposed sex change was irreversible, and therefore could perhaps cause a great deal of psychological and social trauma, the true transsexuals were determined to seek surgery by any means rather than give up the attempt. Suicide as an alternative was contemplated by 4 of the true transsexuals. The drive for sex change was not so intense in the nontrue transsexuals. They were indecisive about their future plans if denied surgery.
All patients except one were aware of the possibility that their sex performance after surgery may not be satisfactory, and that they would not be able to have children. Five subjects were already living in the future role of the opposite sex and had started medico-legal procedures for future problems like change of name, identity etc. [Table 2] and [Table 3].
The I.Q. was above the average in all except one case. The MMPI showed elevation on the hostility index in the case of true transsexuals, while the Masculine/Feminine index was border line. The scores for the Masculinity/ Feminity scale and schizophrenia were both high in the rest of the subjects. The true transsexuals showed normal extraversion and neuroticism scores on the Eysenck Personality Inventory, while the others had high neuroticism and low extraversion scores. The Rorschach test More Details helped to distinguish the schizophrenics from the other patients [Table 4].
To the best of our knowledge, this is the first occasion on which the psychiatric aspects of this unusual and interesting subject are being reported from our country.
Although the exact incidence of transsexualism in India is not known, Pauly , has estimated an incidence of 1 in 100,000 for U.S.A. However the fact that we could collect 12 subjects in almost as many months indicates that it is not so rare. The male/female ratio has been reported from Western countries to vary between 2:1 and 10:1 in favour of males.  Both the sexes were almost equally represented in our series. Perhaps this was the case because of the socially inferior position of women in India as compared to the developed countries. It is also significant that all the subjects were referred by a surgeon and none of them had requested psychiatric help primarily.
The etiology of transsexuality is still to be worked out, but there are 3 theoretical possibilities, namely:
The first postulate is unlikely as this would result in intersex or hermaphroditism, rather than transsexualism.
This syndrome is relatively unknown even to physicians. They believe that this is a variant of homosexuality or transvestism, or that most of these subjects are borderline or overt schizophrenics.
This condition is to be distinguished from several others. [Table 5].
It can be differentiated from transvestism by the fact that for the transvestite, cross-dressing is the goal of sexual fulfillment and it is accompanied by sexual arousal.
The passive homosexual prizes his genitals and would never consent to their removal. By contrast, the true transsexual is disgusted by his genital organs and looks forward to their removal or often self-mutilates.
Transsexualism as a paranoid delusion may be a primary symptom of schizophrenia. But here it does not exist in pure culture and other psychotic symptoms are invariably present.
The distinction between transsexuality and temporal lobe epilepsy is not difficult to make because in the latter instance the abnormal behaviour is episodic and recurrent and may be accompanied by amnesia for the event.
These patients cannot be labelled as malingerers. A malingerer feigns or protracts one's illness with an intent to deceive. It is usually encountered in criminal cases, cases involving compensation and personal injuries, or military or similar special services. The diseases most likely to be malingered are psychoses, amnesias, psychoneuroses and mental deficiency. The condition of transsexualism is not included in this list. 
Hermaphroditism can be distinguished from transsexualism by the presence of ambiguous genitals and chromosomal studies. 
Above all, the persistence with which the true transsexual seeks change of sex distinguishes this condition from all others.
Reversals are rare once this syndrome is established. F. Z. Abraham  is said to have performed the first gender-reassignment operation in the 1930's.  In 1953 Hamburger et al  reported the case of Christian Jorgensen and thereafter surgical sex reassignment has become wellknown. Subsequently Johns Hopkins Hospital, University of Minnesota Hospitals, have become famous pioneering centres for sex-change operations. Conventional psychotherapy, behaviour modification, ECT and treatment with psychotropic drugs have not showed any promising results.  Until 1975 there was only one case where psychoanalysis had succeeded.  It is believed that the failure of all types of conservative treatment is because of poor motivation. Therefore the sheet-anchor of therapy is management rather than a radical cure. Although not enough by itself, the fact that surgery can successfully help the patient to a better social and inner adjustment is very well documented. 
Benjamin (1963)  in his followup study of 50 male patients who had undergone surgery, reported that only one remained dissatisfied, 5 complained about their sexperformance or appearance, while 44 reported social and sexual contentment as females.
Pauly (1968), , in a similar follow-up study of 110 male patients, reported that the satisfactory outcome outnumbered the unsatisfactory outcome by 10:1. Similar observations have been reported by Hertz et al (1961)  and Hoenig in their small series.  Pauly (1965)  and Benjamin (1966)  have also reported an excellent outcome for female transsexuals. 
Dissenting opinions about genderreassignment surgery include objections such as the fact that the surgery is irreversible and mutilating, and that there are patients who have not made satisfactory adjustments after operation. This is true in principle. However the same objections are also valid for similar types of surgical intervention for other conditions e.g., evisceration for intraabdominal cancer, nephrectomy, mastectomy etc. The argument that this surgery is life saving in the latter instances is not very valid, if simultaneously one appreciates the quality of life which the transsexuals would be leading if they were to be denied surgery.
It has also been mentioned that some patients develop psychosis after surgery. It is very difficult to state with certainity that psychosis would not have occurred otherwise, and that the two are causally related. Moreover there is no evidence to suggest from the follow-up reports that there is a large incidence of psychosis after gender-reassignment surgery.  A careful and intensive psychiatric evaluation before surgical intervention would help to eliminate patients who are already psychotic prior to surgery. The postoperative psychiatric morbidity in the operated minority is mostly centered around problems of readjustment and gender-role performance rather than a true psychosis.
The increase in acceptance of the operation has raised important religious, medical and ethico-legal issues, namely
In most discussions the first and second are not questioned. The third point is complex and legal aspects surrounding the operation are not resolved. However in Britain the operation is covered by the National Health Scheme. In the United States, 1.5 states have permitted postoperative changes in birth records. 
In brief, Belgian, Swedish, Danish, Dutch and Swiss law makes the operation legal. In Canada the operation is legal if it can be shown that the subject is in distress and would benefit from treatment. 
In this country there is no legal provision for or against sex-change surgery. At this stage, no dogmatic opinion can be given regarding criteria for suitability for sex-change surgery as the subject is still controversial. However, as mentioned by Hoenig,  the indications and conditions for the operation formulated by Benjamin (1966)  are worth mentioning. They are
In conclusion the very many problems posed by this syndrome remind us of the following lines written by Arthur Guiterman  and Alfred Kreymberg  (circa 1800) and quoted by Maurice Strauss  :
`Amoebas at the start were not complex,They tore themselves apart and so created sex.' 
`Some sexes change their sexes now,And make a mere mortal wonder how.' 
The authors thank Dr. C. K. Deshpande, Dean, Seth G.S. Medical College & K.E.M. Hospital, Bombay-400012 for permission to conduct and publish this study.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]