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The male to female transsexual : a case study Blanchard, Daniel Norman 1988

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THE MALE TO FEMALE TRANSSEXUAL: A CASE STUDY by DANIEL N O R M A N B L A N C H A R D B.A. University of British Columbia  1980  A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF ARTS in  T H E F A C U L T Y OF G R A D U A T E STUDIES T H E F A C U L T Y OF E D U C A T I O N T H E D E P A R T M E N T OF C O U N S E L L I N G PSYCHOLOGY  We accept this Thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH COLUMBIA May  1988  © D a n i e l Norman Blanchard,  1988  In  presenting  degree freely  at  this  the  available  copying  of  department publication  this or of  thesis  partial  fulfilment  University of  British  Columbia,  for  and  reference  thesis by  this  in  for  his thesis  scholarly  or for  her  of  The University of British Columbia Vancouver, Canada  DE-6 (2/88)  I further  purposes gain  the  requirements  I agree  shall  that the  agree that  may  representatives.  financial  permission.  Department  study.  of  It not  be  by  understood be  an  advanced  Library shall  permission  granted  is  for  for  the that  allowed without  head  make  it  extensive of  my  copying  or  my written  - ii -  ABSTRACT This  study  was  undertaken  to  examine  adjustment of a male-to-female transsexual.  the  development  and  ongoing  R e l y i n g p r i m a r i l y on i n t e r v i e w s  with  the case s u b j e c t , selected f r i e n d s a n d f a m i l y m e m b e r s , the research a t t e m p t e d to u n c o v e r i n c i d e n t s w h i c h were c r i t i c a l i n this person's post o p e r a t i v e and  social  adjustment.  guidelines  set  down  accordance  with  The  by  interviews  Flanagan  the e c o - s y s t e m i c  were  conducted  (1954).  The  framework  put  in  incidents forth  by  psychological  accordance  were  with  classified  Conger  (1981).  in  This  t h e o r e t i c a l f r a m e w o r k e m p h a s i z e d the c o n t e x t w i t h i n w h i c h the i n c i d e n t s o c c u r r e d . Psychological instruments: McKinlcy,  and The  social  adjustment  Minnesota  1967); T h e  were  Multiphasic  Social Support  assessed  Personality  Questionnaire  by  three  Inventory  (Sarason,  standardized (Hathaway  Lcvinc  &  &  Basham,  1983) ; a n d T h e F a m i l y Assessment M e a s u r e ( S k i n n e r , S t e i n h a u c r , & S a n t a - B a r b a r a , 1984) . D u r i n g the course of the i n t e r v i e w s revealed.  a total of 30 " c r i t i c a l i n c i d e n t s "  were  O f the 30 i n c i d e n t s , 22 of them were c l a s s i f i e d at the " c o m m u n i t y " level  of analysis.  T h i s result u n d e r s c o r e d  the i m p o r t a n c e o f  various community  systems or g r o u p s , at both the pre- a n d post o p e r a t i v e stages. i n c i d e n t s were  level  O n c e c l a s s i f i e d , the  r a t e d , by both the case subject a n d case i n v e s t i g a t o r ,  r e l a t i v e i m p o r t a n c e to the i n d i v i d u a l ' s post o p e r a t i v e a d j u s t m e n t .  in terms of  These incidents  were then d i s c u s s e d i n terms of three p r i m a r y themes: a c c e p t a n c e versus  rejection,  c o m p e t e n c y versus i n c o m p e t e n c y , a n d i s o l a t i o n versus b e l o n g i n g . In  addition  to  the  critical  incidents,  a  series  i n f l u e n c e s were r e v e a l e d d u r i n g the i n t e r v i e w process. classified  in  terms  of  situational influences  Conger's were  (1981)  discussed i n  style a n d i n t e r p e r s o n a l r e l a t i o n s h i p s .  eco-systemic terms of  of  ongoing  situational  T h e s e i n f l u e n c e s were also classification  two  primary  system.  themes:  The  personal  - Ill -  T A B L E OF C O N T E N T S ABSTRACT LIST OF T A B L E S LIST OF F I G U R E S LIST OF A P P E N D I C E S ACKNOWLEDEMENTS  i i  v  i  i v v vi i  CHAPTER I INTRODUCTION N a t u r e of the P r o b l e m P u r p o s e of the S t u d y Ecological-Systems Model Research Questions  1 2 3 5 7  CHAPTER II REVIEW OF THE R e s e a r c h on R e s e a r c h on R e s e a r c h on  LITERATURE C l a s s i f i c a t i o n and D i a g n o s i s Etiology Treatment Outcome  9 9 17 20  CHAPTER III METHODOLOGY T h e Case S t u d y T h e Case Subject T h e Case S t u d y I n v e s t i g a t o r The Semi-Structured Interview The C r i t i c a l Incident Technique T h e C r i t i c a l I n c i d e n t Scale Standardized Instruments Minnesota Multiphasic Personality Inventory T h e F a m i l y Assessment M e a s u r e Social Support Questionnaire  32 32 34 36 37 45 46 47 48 50 52  CHAPTER IV RESULTS Introduction M M P I P r o f i l e Interpretations F a m i l y Assessment M e a s u r e The Social Support Questionnaire The C r i t i c a l Incidents Situational Influences  "  56 56 56 61 74 75 77  CHAPTER V S U M M A R Y A N D DISCUSSION T h e Test R e s u l t s The C r i t i c a l Incidents The Situational Influences U n d e r l y i n g Themes Research Questions: Conclusions The Results Within The Context O f Other Research L i m i t a t i o n s of the S t u d y I m p l i c a t i o n s a n d Suggestions F o r F u t u r e R e s e a r c h  REFERENCES  80 81 84 88 90 91 93 96 97 99  - iv -  LIST OF  TABLES  T A B L E 1.1 T h e E c o l o g i c a l Systems F r a m e w o r k T A B L E 3.1 A n E x a m p l e of the C o m m u n i t y C l a s s i f i c a t i o n T A B L E 4.1 E c o - S y s t e m i c C l a s s i f i c a t i o n of C r i t i c a l I n c i d e n t s T A B L E 4.2 E c o - S y s t e m i c C l a s s i f i c a t i o n of S i t u a t i o n a l I n f l u e n c e s T A B L E 4.3 A C o m p a r i s o n of the Case Subject's and Case I n v e s t i g a t o r S i g n i f i c a n c e R a t i n g s of the C r i t i c a l I n c i d e n t s  LIST OF FIGURES FIGURE 3.1 Schedule of Data Collection FIGURE 4.1 1971 M M P I P r o f i l e FIGURE 4.2 1975 M M P I P r o f i l e FIGURE 4.3 1987 M M P I P r o f i l e FIGURE 4.4 T h e G e n e r a l Scales FIGURE 4.5 T h e D y a d i c R e l a t i o n s h i p Scales T h e Case Subject a n d her M o t h e r : FIGURE 4.6 T h e D y a d i c R e l a t i o n s h i p Scales T h e C a s e Subject a n d her B r o t h e r FIGURE 4.7 T h e D y a d i c R e l a t i o n s h i p Scales T h e Case Subject a n d her F a t h e r FIGURE 4.8 The Self R a t i n g Profile  - VI -  LIST OF A P P E N D I C E S APPENDIX A Letters of Introduction APPENDIX B Consent Forms APPENDIX C A Detailed Interview Guide APPENDIX D The 'General' Interview Guides. APPENDIX E A Thematic Classification  - Vll -  ACKNOWLEDGEMENTS T h e r e are a n u m b e r o f people w h o have p l a y e d s i g n i f i c a n t roles i n the p r o d u c t i o n o f t h i s thesis a n d I w o u l d l i k e to take this o p p o r t u n i t y to a c k n o w l e d g e them. D r . J o h n F r i e s e n , the c h a i r p e r s o n o f m y thesis c o m m i t t e e , has been a source o f m u c h e n c o u r a g e m e n t a n d e n t h u s i a s m f r o m the i n c e p t i o n o f t h i s project to its • c o m p l e t i o n . D r . R o b e r t C o n r y g u i d e d me i n the e x e c u t i o n o f a m e t h o d o l o g y w h i c h at times I f o u n d c o n f u s i n g a n d u n c l e a r . H i s c o m m e n t s were as i n s i g h t f u l as his h u m o r e n j o y a b l e . I w o u l d also l i k e to a c k n o w l e d g e the t h i r d m e m b e r o f my c o m m i t t e e , D r . R o b e r t T o l s m a , whose suggestions r e g a r d i n g the i n t e r v i e w guides h e l p e d to f o c u s m y thoughts i n this a r e a . I w a n t to t h a n k m y p a r e n t s , C l a r a a n d D o u g , whose u n c o n d i t i o n a l b e l i e f in my a b i l i t i e s has a l w a y s been a source o f s u p p o r t , a n d sometimes o f r e f u g e . W i t h o u t m y p a r t n e r T o m , w h o p r o v i d e d e v e r y t h i n g f r o m 'tea a n d s y m p a t h y ' to e x p e r t c o m p u t e r a d v i c e , I'm not sure that I w o u l d ever have f i n i s h e d . T h a n k you T o m . A n d f i n a l l y I w a n t to a c k n o w l e d g e T e r r y , m y case subject a n d c o researcher. H e r g e n e r o s i t y , openness a n d p a t i e n c e w i t h m y endless q u e s t i o n s made this project possible. T h r o u g h o u t the course o f o u r c o n v e r s a t i o n s I c a m e more a n d more to a d m i r e the fearlessness w i t h w h i c h she e x a m i n e d her o w n h i s t o r y . She w i l l a l w a y s have my g r a t i t u d e a n d a d m i r a t i o n .  - 1 -  CHAPTER I  INTRODUCTION  T r a n s s e x u a l i s m is the c o n v i c t i o n i n a b i o l o g i c a l l y n o r m a l person of b e i n g a m e m b e r o f the o p p o s i t e sex.  T h i s b e l i e f is sometimes a c c o m p a n i e d by a request for  s u r g i c a l a n d e n d o c r i n o l o g i c a l p r o c e d u r e s that c h a n g e a n a t o m i c a l a p p e a r a n c e to that o f the o p p o s i t e sex  ( S t o l l e r , 1968).  T h e D S M III (1980) d e f i n e s the p h e n o m e n o n as  "a heterogeneous d i s o r d e r o f gender i d e n t i t y (the sense o f k n o w i n g to w h i c h sex one belongs)."  The  primary  f e a t u r e s are "a persistent sense of  discomfort  and  i n a p p r o p r i a t e n c s s about one's a n a t o m i c sex a n d a persistent w i s h to be r i d of one's g e n i t a l s a n d to l i v e as a m e m b e r of the other sex." (p. 261-262) T h e issue of c l a s s i f i c a t i o n a n d d i a g n o s i s has been one o f o n g o i n g debate: a debate w h i c h c o n t i n u e s t o d a y .  P a r a l l e l w i t h e f f o r t s to d i a g n o s e , there has been a  c o n c e r t e d a t t e m p t to d i s c o v e r the cause(s) of this s e e m i n g l y a b e r r a n t p e r c e p t i o n of gender i d e n t i t y .  The  results of this s t r e a m of research r e m a i n e q u i v o c a l .  w r i t e r s arc now suggesting that the m a j o r i t y  of  Some  the e v i d e n c e p o i n t s to a ' s o c i a l  l e a r n i n g ' basis f o r the d e v e l o p m e n t o f the s y n d r o m e ( H o u l t , 1983/84), w h i l e others take a more interactive etiology  (Hoenig,  1985).  stance between Ethical,  biological and psychological  legal  r e a s s i g n m e n t h a v e been a r g u e d as w e l l .  and  medical  theories  implications  R e s u l t s o f o u t c o m e s t u d i e s now  of  of sex-  suggest  that f o r an a p p r o p r i a t e l y d i a g n o s e d g r o u p , s u r g i c a l s e x - r e a s s i g n m e n t docs appear as the best o p t i o n ( H u n t a n d H a m p s o n , 1980; A b r a m o w i t z , 1986). T h o u g h m a n y of these issues are c o m m o n to the s t u d y f e m a l e t r a n s s e x u a l s , this s t u d y  o f both male and  focuses p r i m a r i l y on the p h e n o m e n o n of the male  (i.e. b i o l o g i c a l l y male) t r a n s s e x u a l .  A n e x p l o r a t o r y , s i n g l e case d e s i g n was selected  to s t u d y an i n d i v i d u a l m a l c - t o - f e m a l e post o p e r a t i v e t r a n s s e x u a l w h o has l i v e d in  - 2 the c o m m u n i t y successful  manner.  classification subject  to  and  illuminate adjustment  f o r a s i g n i f i c a n t length of time ( f o u r t e e n years) i n an The  the  'critical  significant the  range  and  to  analysis  incidents'  others of  attempts  in  her  influences  increase  the  to  gleaned  life.  apply from  The  an  ecological  interviews  purpose  apparently  of  systems  with  the  this a n a l y s i s  is to  which  have  affected  her  empirical  data  base  malc-to-female  on  post  case  operative post  operative transsexuals.  Nature of the problem Examples  of  what  we  now  term  as t r a n s s e x u a l i s m  have  been  recorded  t h r o u g h o u t h i s t o r y (Steiner, 1981), a l t h o u g h s c i e n t i f i c s t u d y of the p h e n o m e n o n has been p r i m a r i l y l i m i t e d to the last f o r t y years. 1947.  In the  1950's, the case of C h r i s t i n e J o r g e n s o n  p o p u l a r press ( B a l l , 1981). the  T h e t e r m was c o i n e d by C a l d w e l l in  intervention  consciousness.  of  was r e p o r t e d  psychiatric  in  the  F o r the f i r s t t i m e , the c o n d i t i o n of t r a n s s e x u a l i s m a n d  sex-reassignment  Accompanying  this  surgery increase  began in  to  public  c o r r e s p o n d i n g i n c r e a s e i n d e m a n d f o r the s u r g e r y ( B a l l , 1981). the  widely  community  was  faced  with  an  enter  the  awareness  public was  a  As a consequence,  increasingly  heterogeneous  p o p u l a t i o n r e q u e s t i n g s e x - r e a s s i g n m e n t ( B a l l , 1981). Due  to  this  heterogeneity  in  the  patient/client  d i a g n o s i s a n d c l a s s i f i c a t i o n became i n c r e a s i n g l y c o m p l e x . was f r a u g h t w i t h d i s a g r e e m e n t .  population,  issues  of  R e s e a r c h i n t o this area  T h o u g h a v a r i e t y o f schemas were i n t r o d u c e d , the  issue r e m a i n s c o n t e n t i o u s to this d a y . A s s c i e n t i f i c interest i n c r e a s e d , e t i o l o g i c a l issues became a p r i m a r y f o c u s of study.  A g a i n , results were c o n f l i c t i n g ; some a u t h o r s suggested that the m a j o r i t y  of  the e v i d e n c e s u p p o r t s a ' s o c i a l l e a r n i n g ' m o d e l of e t i o l o g y ( H o u l t , 1983/84)  while  other a u t h o r s s u p p o r t e d the v i e w that p s y c h o l o g i c a l f a c t o r s m a y come i n t o  effect  - 3 o n l y i f a b i o l o g i c a l p r e d i s p o s i t i o n is f i r s t i n place ( H o e n i g , 1985; M o n e y , H a m p s o n a n d H a m p s o n , 1957). S t u d i e s o f t r e a t m e n t o u t c o m e suggest that s e x - r c a s s i g n m c n t s u r g e r y preferred  mode  of  treatment  in  a  select  i n d i v i d u a l s ( H u n t a n d H a m p s o n , 1980).  group  of  appropriately  is the  diagnosed  R e s e a r c h also i n d i c a t e s that s u r g e r y  does  not p r e c l u d e the use of p s y c h o t h e r a p y i n d e a l i n g w i t h both p r e - a n d post o p e r a t i v e issues ( L o t h s t e i n , 1983). operative  adjustment  In a d d i t i o n it appears that i n the m a j o r i t y of cases, post  is s i g n i f i c a n t l y  affected  (positively)  c o n j u n c t i o n w i t h m e d i c a l t r e a t m e n t ( L o t h s t e i n , 1980).  by  psychotherapy  Some a u t h o r s have  in  recently  suggested, h o w e v e r , that the f r e q u e n c y of c l a s s i f i c a t i o n as ' s u r g i c a l l y  appropriate'  t r a n s s e x u a l s has been too great a n d that i n c e r t a i n cases, n o n - s u r g i c a l  interventions  (i.e. p s y c h o t h e r a p y ) w o u l d be more s u c c e s s f u l ( L o t h s t e i n , 1983).  P u r p o s e of the S t u d y T h o u g h interest as w e l l as d i s a g r e e m e n t in areas of e t i o l o g y , t r e a t m e n t , and c l a s s i f i c a t i o n is o n g o i n g w i t h i n individuals transsexual.  displaying In  the s c i e n t i f i c c o m m u n i t y , we arc s t i l l f a c e d  symptoms  which  meet  various  addition, medical intervention  criteria  i n the f o r m  for  of  with  diagnosis  as  sex-rcassignmcnt  s u r g e r y ( S R S ) is p e r f o r m e d i n v a r i o u s c o u n t r i e s , i n c l u d i n g C a n a d a .  It appears that  we are not i n a p o s i t i o n w h e r e p r c - o p e r a t i v e issues m a y be s t u d i e d  exhaustively  b e f o r e b e g i n n i n g the s t u d y o f post o p e r a t i v e ones. Accepting  that  at  conjunction with SRS for this s t u d y  was to e x p l o r e  present  psychotherapeutic  intervention  the most p o s i t i v e post o p e r a t i v e the f o r m  this i n t e r v e n t i o n  useful  in  p r o g n o s i s , the goal of  (i.e. p s y c h o t h e r a p y )  o p t i m a l l y t a k e , a n d the g e n e r a l issues on w h i c h it m i g h t f o c u s . between  is  might  Though differences  i n d i v i d u a l s s u r e l y e x i s t , e m p i r i c a l research i n areas such as  psychiatry,  c l i n i c a l p s y c h o l o g y , a n d c o u n s e l l i n g p s y c h o l o g y has p r o v i d e d t h e o r y a n d statements  - 4 of p r i n c i p l e .  S u c h i n f o r m a t i o n guides t h e r a p i s t s i n t h e i r w o r k  with  Statements o f p r i n c i p l e a n d t h e o r y appear to have been l a c k i n g f o r  individuals. the  persons  T h e purpose of this study has been to r e v e a l the d e v e l o p m e n t a n d  ongoing  d e s c r i b e d as t r a n s s e x u a l .  a d j u s t m e n t o f an i n d i v i d u a l focus d i f f e r s  from  that  w i t h i n the c o n t e x t  of  most o f  o f her l i f e c i r c u m s t a n c e s .  the p u b l i s h e d  research  (e.g.  This  R a n d e l l , 1969;  S k a p e c a n d M a c k e n z i e , 1981), w h i c h appears l a r g e l y to h a v e i g n o r e d the i m p a c t of the f a m i l y , the m e d i c a l , p s y c h i a t r i c , a n d legal p r o f e s s i o n s , a n d other groups  which  s u r r o u n d the i n d i v i d u a l a n d c o m p r i s e the c o n t e x t w i t h i n w h i c h l i f e is l i v e d .  The  e x c e p t i o n to this s i t u a t i o n arc c e r t a i n studies c i t e d w h i c h f o c u s on the e t i o l o g y  of  the t r a n s s e x u a l s y n d r o m e . Bronfenbrenner which  views  Conger's  the  (1981)  (1977) proposed an e c o l o g i c a l systems m o d e l f o r  reciprocal adaptation  interaction of  i n d i v i d u a l case, the present  this  of  model  a series o f as  the  "nested  basis  for  the  research  systems."  Using  analysis  research e x a m i n e d how s u c h 'systems' as the  peer g r o u p , m e d i c a l a n d e d u c a t i o n a l agencies have i n f l u e n c e d the post  of  an  family,  operative  a d j u s t m e n t o f the i n d i v i d u a l . T h i s s t u d y docs not p r o v i d e d e f i n i t i v e a n s w e r s , it does h o w e v e r e n r i c h e x i s t i n g k n o w l e d g e base i n the area of t r a n s s e x u a l i s m .  P e r h a p s more  the  importantly,  by t a k i n g the case s t u d y a p p r o a c h , a n d e x a m i n i n g w h a t f a c t o r s are p e r c e i v e d as significant interacted  in  this  to a f f e c t  person's this  post  operative  i n d i v i d u a l , the s t u d y  adjustment, provides  and  how  they  have  an alternative  focus  to  an  systemic  m u c h of the p u b l i s h e d research i n this a r e a . This  project  contributes  to  the  development  of  ecological,  u n d e r s t a n d i n g of post o p e r a t i v e t r a n s s e x u a l a d j u s t m e n t f r o m w h i c h c l i n i c i a n s may d r a w w h e n c a l l e d upon to i n t e r v e n e w i t h this p o p u l a t i o n .  - 5The Ecological-Systems Model C e n t r a l to systems t h e o r y is the b e l i e f that the v a r i o u s elements o r parts a b o u n d e d u n i t (i.e. a system) are i n t e r d e p e n d e n t .  of  A s each e l e m e n t acts a n d reacts,  it c a n n o t h e l p but h a v e an e f f e c t , e i t h e r d i r e c t l y or i n d i r e c t l y , u p o n other elements w h i c h i n t u r n react a n d h a v e a n e f f e c t on the o r i g i n a l u n i t at some later moment i n t i m e ( C o n g e r , 1981).  H i s t o r i c a l l y , systems theorists have d e f i n e d this ' b o u n d e d  u n i t ' as b e i n g the f a m i l y ( H a l e y , 1963).  T h e result o f t h i s d e f i n i t i o n was a f o c u s  on the ' f a m i l y s y s t e m ' a n d the v a r i o u s subsystems w h i c h c o m p r i s e it. Bronfenbrenner  (1977, 1979) proposed an e x p a n s i o n of  study of c h i l d development.  this m o d e l f o r  E m p h a s i z i n g the n o t i o n of ' r e c i p r o c i t y '  the  (interacting  a n d m u t u a l l y a f f e c t i n g elements), he proposed that the f a m i l y be v i e w e d a s one  of  a series o f m i c r o - s y s t e m s w h i c h a f f e c t the d e v e l o p i n g c h i l d .  of  In his d e s c r i p t i o n s  the d i f f e r e n t levels o f systems, he gave e x a m p l e s w h i c h a p p l i e d as to c h i l d r e n . developing  well  T h i s suggests that he v i e w e d the i n d i v i d u a l as a d y n a m i c system  throughout  transition' (where result o f  to a d u l t s a s  the  life  cycle.  the i n d i v i d u a l ' s  Coupled  with  p o s i t i o n is c h a n g e d  his in  change i n r o l e , s e t t i n g , or both [1979, p. 26]), it  notion  of  'ecological  the e n v i r o n m e n t would  seem that  a s a the  e c o l o g i c a l systems m o d e l is a n a p p r o p r i a t e m o d e l f o r s t u d y i n g the e n t i r e l i f e c y c l e , a n d is not l i m i t e d to a s t u d y o f c h i l d h o o d . Conger  (1981), b u i l d i n g on the w o r k  m o d e l f o r b e h a v i o r a l assessment o f f a m i l i e s .  of B r o n f e n b r e n n e r  proposes his  own  " F o l l o w i n g B r o n f e n b r e n n e r (1979), we  are c o n c e r n e d w i t h the r e c i p r o c a l i n f l u e n c e s that i n d i v i d u a l c h a r a c t e r i s t i c s , f a m i l y d y n a m i c s , a n d t r a n s a c t i o n s w i t h the o u t s i d e c o m m u n i t y have on one another." (p. 202)  T h e f o c u s is on the c r e a t i o n o f a f r a m e w o r k w h i c h stresses the i n t e r a c t i o n of  three p r i m a r y  levels o f a n a l y s i s .  T h e levels of a n a l y s i s a n d i l l u s t r a t i v e measures  proposed by C o n g e r are s u m m a r i z e d i n T a b l e 1.1.  -6 T A B L E 1.1 T H E ECOLOGICAL SYSTEMS FRAMEWORK  Level of Analysis  Illustrative Measures  1. The individual family member  a. b. c. d. e.  2. The family system  a. Structure (1) number of adults (2) number of children (3) ages of parents and children (4) living conditions b. perceptions and attributions by family members to one another c. patterns of interaction  3. The community  a. Social position: (1) economic status (2) educational success (3) geographic location (4) desirability of employment b. Contacts with social agencies (1) voluntary as desired (2) coercive - economically necessary or instigated by others c. Social relationships (1) friendship networks (2) extended family (p. 202)  Social background (parents) Experiences in family of origin Mood: depression Intellectual functioning Excessive, deficient, or inappropriate behavioral characteristics  This table is based on a systemic conceptualization involving circular and reciprocally interacting relationships.  Conger views the individual as embedded  within the family and the family within the community.  This schema emphasizes  the series of "nested systems" which form a dynamic and interacting context within which assessment can take place at any or all of the levels of analysis.  - 7 Research Questions What are the s i g n i f i c a n t f a c t o r s i n the post o p e r a t i v e a d j u s t m e n t of a m a l c to-female transsexual?  What are the consequences of these f a c t o r s , a n d w h y  they seen as s i g n i f i c a n t i n the subject's post o p e r a t i v e a d j u s t m e n t ?  arc  A m o n g factors  i d e n t i f i e d as s i g n i f i c a n t , w h a t is t h e i r o r d e r o f s i g n i f i c a n c e ?  Definitions  Transsexual O'Gourman sexual  identity  in  p s y c h o l o g i c a l sex. sex."  For  the  experienced  (1982, p.23) d e f i n e s t r a n s s e x u a l i s m as " . . . which  the  patient's  morphological  is  incongrucnt  of  with  T h e p a t i e n t p e r s i s t e n t l y seeks to l i v e as a m e m b e r of the other  purpose  of  this  process  of  diagnosis, screening, and  the  sex  a disturbance  study,  the  individual  under medical  investigation intervention  had (sex-  r e a s s i g n m e n t s u r g e r y ) a n d had l i v e d post o p e r a t i v e l y as a w o m a n f o r some f o u r t e e n years p r i o r to the s t u d y . Adjustment In  this  study,  'adjustment'  focused  on  the  individual's  level  of  p s y c h o l o g i c a l a n d s o c i a l f u n c t i o n i n g as m e a s u r e d by s e l f - r e p o r t i n s t r u m e n t s . assessed i n c l u d e d : -family functioning, -interpersonal relationships and social support, -self image, and -psychological functioning Pre-operative Transsexual A t r a n s s e x u a l person b e f o r e s e x - r e a s s i g n m e n t s u r g e r y .  both Areas  - 8 -  Post Operative Transsexual A t r a n s s e x u a l person a f t e r s e x - r e a s s i g n m e n t s u r g e r y .  Significant Factors A  significant  factor  may  be a n  individual  event  (e.g. d i s c l o s u r e  to  the  f a m i l y o f the subject's desire f o r s e x - r e a s s i g n m e n t s u r g e r y ) or a s i t u a t i o n or set of c i r c u m s t a n c e s over some d i s c r e t e p e r i o d of time (e.g. e c o n o m i c d i f f i c u l t i e s ) . Data  were  generated  by  using  several  methods:  self-report;  reports  of  s i g n i f i c a n t others, i n c l u d i n g f a m i l y , friends, i n v o l v e d professionals; and data f r o m past  medical/psychological  assessment i n s t r u m e n t s ) .  records  of  the  individual,  (including  standardized  In a d d i t i o n , f a c t o r s g l e a n e d f r o m the research l i t e r a t u r e  were i n v e s t i g a t e d f o r a p p l i c a b i l i t y to the case subject. The  factors  were  elicited  through  an  interview  process,  and  their  s i g n i f i c a n c e was assessed q u a l i t a t i v e l y u s i n g statements of the case subject, f a m i l y and friends.  - 9-  C H A P T E R II REVIEW OF T H E L I T E R A T U R E  This review of the of the current research literature on transsexualism and gender  dysphoria  focuses  primarily  on  the  three  major  topics  of  diagnosis/classification, etiology, and treatment (including studies of treatment outcome).  They are surveyed here not only for their prevalence in the research  literature, but also for this writer's supposition that they cannot truly be separated from each other (i.e. opinions about one topic cannot help but influence opinions on the others).  It is also this writer's supposition that the treatment community's  opinions and beliefs about these topics will strongly affect the experience of the transsexual person seeking sex-reassignment surgery.  Research on C l a s s i f i c a t i o n and Diagnosis  O'Gourman (1982, p. 23) defined transsexualism as " . . . a disturbance of sexual identity in which the patient's morphological sex is incongrucnt with psychological sex. The patient persistently seeks to live as a member of the other sex."  Jan Morris, a post operative (male) transsexual, defined it as " . . . its classic  form  is as distinct  from transvestism  as it is from  Transsexualism is something different in kind. preference.  homosexuality . . . .  It is not a sexual  mode or  It is not an act of sex at all. It is a passionate, lifelong, ineradicable  conviction . . . " (1974, p. 8). For the past forty years, research has attempted to classify this state of psychological  and  morphological  incongruence,  termed  as  "transsexualism"  (Caldwell, 1947). Though specific terms have varied, efforts have been directed at classification  and distinction  of  'primary'  transsexualism  from  'secondary'  - 10 t r a n s s e x u a l i s m (transvestites  or  homosexuals requesting  sex-reassignment  surgery  [SRS]) ( B a l l , 1981; R o t h a n d B a l l , 1964). Benjamin  (1966)  developed  a  seven-category  "Sex  Orientation  d e s c r i b i n g w h a t he saw as a c o n t i n u u m of gender o r i e n t a t i o n .  Scale,"  The first  category  was i n part d e s c r i b e d as " . . . a n y person of n o r m a l sex a n d gender o r i e n t a t i o n f o r w h o m ideas of c r o s s - d r e s s i n g or sex change are c o m p l e t e l y f o r e i g n a n d d e f i n i t e l y u n p l e a s a n t , w h e t h e r the person is hetero, b i - or h o m o s e x u a l " (in O l c s , 1977, p . 68). The  r e m a i n i n g categories f o l l o w e d  were  represented  as:  Pseudo  f r o m this e x t r e m e Transvestite,  a l o n g the c o n t i n u u m  Fetishistic  Transvcstitc,  Transvcstite, Non-Surgical Transsexual, True Transsexual—Moderate True Transsexual—High behavior  of  Intensity.  c r o s s - d r e s s i n g but  and True  I n t e n s i t y and  T h e l a t t e r six categories a l l s h a r e d the o u t w a r d  with  varying  degrees  of  with  identification  the  c r o s s - g e n d e r as w e l l as f r e q u e n c y of the b e h a v i o r . T h e use o f the more recent t e r m 'gender d y s p h o r i a s y n d r o m e ' r e f l e c t s this n o t i o n o f a c o n t i n u u m a n d range of b e h a v i o r s , m o t i v a t i o n s a n d a t t i t u d e s w h i c h arc presented  by  individuals  requesting  sex-reassignment  (Olcs,  1977).  Gender  d y s p h o r i a as a c a t e g o r y subsumes not o n l y that of t r a n s s e x u a l but the e n t i r e range of i n d i v i d u a l s w h o m a y at some t i m e have c r o s s - g e n d e r desires. include  select  transvestites  lesbians (Steiner, gender  dysphoria  1985).  and  some  effeminate  Transsexualism  syndrome.  Though  may the  homosexuals  be v i e w e d  T h i s group and  masculine  as an e x t r e m e  transsexual  may  will  have  of  the  certain  c h a r a c t e r i s t i c s i n c o m m o n w i t h other gender d y s p h o r i c i n d i v i d u a l s , other members of t h i s c l a s s i f i c a t i o n w i l l be d i s t i n g u i s h a b l e due to t h e i r  inconsistency  gender d e s i r e a n d associated n e g a t i v e a f f e c t (i.e. a n x i e t y a n d r e a c t i v e  of cross-  depression)  ( S t e i n e r , 1985). A more recent c l a s s i f i c a t i o n system now Psychiatry  focuses on the v a r i a t i o n s of  gender  in use at the C l a r k e Institute dysphoria  presented.  of  These arc:  - 11 transvestite,  heterosexual  transsexual (Steiner, cross-dressing.  The  transsexual,  1981).  asexual  transsexual  and  homosexual  A l l f o u r categories h a v e i n c o m m o n the b e h a v i o r  t r a n s v e s t i t e i n d i v i d u a l is d e f i n e d as a h e t e r o s e x u a l male w h o  a c h i e v e s f e t i s h i s t i c a r o u s a l by w e a r i n g v a r i o u s items o f f e m i n i n e a t t i r e . times the t r a n s v e s t i t e m a y e x p e r i e n c e gender d y s p h o r i c of a t r a n s i t o r y  of  nature  and consequently  f e e l i n g s , these are  the i n d i v i d u a l  e i t h e r t r a n s s e x u a l or a good c a n d i d a t e f o r S R S .  T h o u g h at  is not  usually  considered  The  latter  be  H o w e v e r , there are r e c o r d e d cases  of d i a g n o s e d transvestites w h o i n m i d d l e age d e v e l o p i n t o t r a n s s e x u a l s (at t i m e the d i a g n o s i s changes).  to  three categories  all experience  which ongoing  gender d y s p h o r i a : they d i f f e r i n s e x u a l o r i e n t a t i o n (object c h o i c e ) a n d not in the o v e r a l l c l a s s i f i c a t i o n of t r a n s s e x u a l .  F r o m this s t a n d p o i n t they arc a l l c o n s i d e r e d  p o t e n t i a l c a n d i d a t e s f o r S R S (Steiner, 1985). A t t e m p t s to c l a s s i f y i n terms o f e i t h e r o f these a n d other s c h e m a have t a k e n a  variety  of  forms.  These  multidisciplinary interview and  neuroendocrinological  have  included  screening  processes  techniques, i n c l u d i n g social, psychological, assessments  (Lothstein  R o d g e r s , S c h u m a c h e r , B a l l a r d , a n d H a r t w e l l , 1978).  1980;  stressing psychiatric  Weathcrhcad,  Powers,  In both o f these studies c i t e d ,  the process was m u l t i - p u r p o s e , i n c l u d i n g : d i a g n o s i s , a c c e p t a n c e to the p r o g r a m SRS,  and  follow-up  on  post-surgical  a d d r e s s e d the need f o r p s y c h o t h e r a p y  adjustment.  Lothstein  (1980)  of  specifically  f r o m the t i m e o f d i a g n o s i s t h r o u g h  surgery  (and a f t e r ) , so as to f a c i l i t a t e i m p r o v e d a d j u s t m e n t to the new role. W e a t h e r h e a d et a l . (1978) r e p o r t e d t h e i r p r o g r a m at the C l e v e l a n d C l i n i c .  that c o u n s e l l i n g was a r e q u i r e m e n t  of  It was c a r r i e d out by a p s y c h i a t r i c s o c i a l  w o r k e r f o r a m i n i m u m of six m o n t h s p r e - o p e r a t i v e l y , a n d post o p c r a t i v e l y , f o r an u n d e s c r i b e d p e r i o d of t i m e . (1) to s u p p o r t  T h e y stated that c o u n s e l l i n g served s e v e r a l  patients in adjusting  to the s o c i a l e n v i r o n m e n t  purposes:  as they begin  process of f u l l time c r o s s - l i v i n g ; (2) to d e v e l o p a c o u n s e l l i n g e n v i r o n m e n t  the  of total  - 12 a c c e p t a n c e w h e r e the p a t i e n t feels f r e e to e x p l o r e a l l areas of self d o u b t ( w h e t h e r or not they are r e l a t e d to t r a n s s e x u a l i s m ) ; (3) to m o n i t o r the c o n t i n u e d m o t i v a t i o n of the p a t i e n t ; (4) to a l l o w f o r a n o n g o i n g i n t e n s i v e e v a l u a t i o n a n d assessment of the  patient.  During  this  process  T h e m a t i c A p p e r c e p t i o n Test.  the  team p s y c h o l o g i s t  would  administer  the  D a t a generated f r o m this test w o u l d be s u p p l i e d to  the t h e r a p i s t f o r f u r t h e r e x p l o r a t i o n (if not a l r e a d y c o v e r e d ) d u r i n g t h e r a p y .  Once  at the p o i n t w h e r e the t h e r a p i s t was p r e p a r e d to c o m m i t the p a t i e n t to the stage of S R S , t h e y (the t h e r a p i s t ) w o u l d r e f e r the p a t i e n t b a c k to the t e a m p s y c h i a t r i s t a n o t h e r assessment ( w h i c h i n c l u d e d a r e w r i t i n g of the o r i g i n a l test b a t t e r y ) .  for  If the  p s y c h i a t r i s t was i n a g r e e m e n t , the case was t h e n put f o r t h to the t r e a t m e n t team as a  whole.  If  the e n t i r e  team a g r e e d , the  patient/client  was  recommended  for  surgery. Q u e s t i o n s c o u l d be r a i s e d r e g a r d i n g h o w t h e r a p i s t s at the C l e v e l a n d were able to p r o v i d e  therapeutic  environments  were  conducting  assessments  simultaneously  r e c o m m e n d a t i o n f o r or against s u r g e r y .  of  Clinic  "total acceptance" when  which  would  contribute  they to  a  W e a t h e r h e a d et a l . (1978) d i d not discuss  t h i s c o n c e r n , a n d how it was dealt w i t h i n t h e i r p r o g r a m . S h u m a k e r , i n c h r o n i c l i n g her e x p e r i e n c e s as a p r e - a n d then post o p e r a t i v e m a l e - t o - f e m a l e t r a n s s e x u a l ( L e v i n e a n d S h u m a k e r , 1983), a d d r e s s e d d i r e c t l y issue o f the t h e r a p u t i c r e l a t i o n s h i p .  this  In d e s c r i b i n g her p r e - o p c r a t i v c t h e r a p y ( w i t h  L e v i n e , her l a t e r c o - a u t h o r ) she stated that she c o n s c i o u s l y l i m i t e d the t h e r a p e u t i c e x p e r i e n c e , b e i n g a l w a y s s l i g h t l y s u s p i c i o u s of her t h e r a p i s t , w h o m she k n e w h o l d m u c h p o w e r over her a b i l i t y to a t t a i n the S R S . that  had p r e - o p e r a t i v e  therapy  to  It is S h u m a k c r ' s c o n t e n t i o n  been e f f e c t i v e at a deeper  l e v e l , it m i g h t  have  h e l p e d to p r e p a r e her f o r the post o p e r a t i v e r e a l i t i e s (and d i f f i c u l t i e s ) w h i c h she w o u l d later f a c e .  - 13 P s y c h o t h e r a p y , w h i l e d i f f i c u l t a n d at times c o n t r o v e r s i a l , has been c e n t r a l i n both issues of d i a g n o s i s a n d a d j u s t m e n t . conducted a four male  and  year s t u d y  of  female transsexuals  K e l l e r , A l t h o f a n d L o t h s t e i n (1980)  the e f f i c a c y of g r o u p t h e r a p y (all  pre-operative).  As  with  a screening  proclaimed device,  m o d a l i t y o f l o n g t e r m g r o u p t h e r a p y was seen as b e i n g h i g h l y e f f e c t i v e .  the  O v e r the  p e r i o d of s t u d y , 4 3 % o f the p a r t i c i p a n t s opted out o f the p r o g r a m a n d , i n e f f e c t , out o f s u r g e r y .  The  a u t h o r s c l a s s i f i e d these as i n s t a n c e s o f t r a n s v e s t i s m .  It  is  i n t e r e s t i n g to note that the g r o u p that d r o p p e d out t e n d e d to be o l d e r (mean age 35) w h i t e males.  What u l t i m a t e l y became o f the p r o g r a m d r o p o u t s a n d  whether  f o l l o w - u p was done w i t h t h e m was not e x p l a i n e d by the a u t h o r s . M o r g a n (1978) presented his e f f o r t s i n an o n g o i n g process of c l a s s i f i c a t i o n , which  included  an  i n i t i a l diagnosis,  followed  by  further  refinement  so as  to  d i f f e r e n t i a t e those i n d i v i d u a l s a p p r o p r i a t e f o r S R S , f r o m those w h o m he j u d g e d w o u l d b e n e f i t f r o m p s y c h o l o g i c a l f o r m s of i n t e r v e n t i o n .  M o r g a n states that, in his  o p i n i o n , "core  1968) is a c o n t i n u u m  gender  w h i c h we a l l reside.  identity"  (as d e f i n e d  by S t o l l e r ,  E x p e r i e n c e , he reports, has s h o w n h i m that the  on  hypothetical  a n d c l a s s i c case of the a n a t o m i c a l male w h o v i e w s his penis as some type of g r o w t h c a p a b l e o f g i v i n g h i m no p l e a s u r e , w h o has a l w a y s t h o u g h t o f h i m s e l f as a w o m a n , w h o presents c o n v i n c i n g l y e x t r e m e l y rare case (p. 274).  to the w o r l d  as s u c h , is a v e r y s t r a i g h t - f o r w a r d  but  T h e m a j o r i t y of p a t i e n t s w h o present as t r a n s s e x u a l s  ( s e l f - d i a g n o s e d ) do not f a l l at this e x t r e m e of the c o n t i n u u m , but r a t h e r s o m e w h e r e closer to the c e n t r e .  A s a result, c l a s s i f i c a t i o n a n d d i a g n o s i s is a process  r e q u i r e s an intense e v a l u a t i o n over an e x t e n d e d p e r i o d of t i m e .  which  M o r g a n says that  the c l i n i c i a n , w h e n e n g a g i n g these i n d i v i d u a l s i n this o n g o i n g process of e v a l u a t i o n a n d t r e a t m e n t , must be p r e p a r e d to d e a l w i t h w h a t he has t e r m e d "the t r a n s s e x u a l i m p e r a t i v e " (the d e t e r m i n e d , u n r e l e n t i n g , a n d sometimes h y s t r i o n i c p u r s u i t of S R S ) . H e estimates that as an o u t c o m e of  the c l a s s i f i c a t i o n / d i a g n o s i s process,  15% of  - 14 t r a n s s e x u a l c a n d i d a t e s w i l l be f o u n d to be s u f f e r i n g f r o m a m a j o r m e n t a l i l l n e s s , 30% w i l l  be classed as ' h o m o p h o b i c  h o m o s e x u a l s ' a t t e m p t i n g to escape a s e x u a l  o r i e n t a t i o n they f i n d a b h o r r e n t , a n d 2 0 % - 2 5 % are s e x u a l l y a m b i g u o u s w h o are g i v e n the d i a g n o s i s of " i n a d e q u a t e p e r s o n a l i t y . " suggests,  are  correct  in  their  assessment  that  they  individuals  T h i s latter g r o u p , M o r g a n  must  make  some  profound  changes i f they are to a c h i e v e a n y sense of s a t i s f a c t i o n a n d h a p p i n e s s f r o m l i f e ; t h e y are i n c o r r e c t , h o w e v e r , transformation.  In  i n l a b e l i n g it as an issue s o l v a b l e by s u r g i c a l  discussing  why  65%-70%  of  individuals  t r a n s s e x u a l are a c t u a l l y s u f f e r i n g f r o m other d i f f i c u l t i e s , M o r g a n concept  of  "the  schizophrenia, connotations.  . . .  transsexual inadequate  imperative." personality  He  and  points  out  that  homosexuality  presenting returns  diagnoses  carry  gender  to his  such  clear  as  as  negative  T r a n s s e x u a l i s m , he asserts:  has somehow escaped the severe censure of these other  three,  perhaps  because it is a d i a g n o s i s l i k e 'acute a p p e n d i c i t i s . ' A f t e r s u r g e r y the d i a g n o s i s goes a w a y .  After  improvement The  the s u r g e r y the t r a n s s e x u a l is a ' w o m a n , ' a c o n s i d e r a b l e  over b e i n g ' c r a z y , '  imperative  of  the  ' i n e p t , ' or ' q u e e r , ' i n  transsexual  candidate  is an  the m i n d s o f  echo  of  most.  the  societal  i m p e r a t i v e to be ' n o r m a l , ' ' r e g u l a r , ' a n d ' s t r a i g h t , ' as this s o c i e t y  defines  these terms, (p. 281)  Descriptions  of  behavior,  congruent  with  Morgan's  concept  of  the  transsexual  i m p e r a t i v e , c a n be f o u n d i n the w r i t i n g s of a n u m b e r of other a u t h o r s (e.g. B a l l , 1981). F o l l o w i n g M o r g a n (1978), M e y e r  (1983) c l e a r l y stated that in his o p i n i o n ,  a p p r o p r i a t e d i a g n o s i s takes place w i t h i n the f r a m e w o r k of o n g o i n g (and l o n g term)  psychotherapy.  Meyer,  in  describing  his  program,  said  relatively  that  if  the  p r o s p e c t i v e p a t i e n t was a c c e p t e d i n t o the p r o g r a m , he or she was then i m m e d i a t e l y  - 15 referred  to e i t h e r g r o u p or i n d i v i d u a l t h e r a p y  (as a p r e r e q u i s i t e  progress t o w a r d S R S , i n c l u d i n g the a d m i n i s t r a t i o n o f a p p r o p r i a t e should  be  noted  guarantees o f  that  individuals  accepted  S R S as a f i n a l o u t c o m e .  into  this  program  to a n y  further  hormones). were  given  M e y e r s a i d that d i a g n o s i s of  t r a n s s e x u a l ' took p l a c e over the course of the w e e k l y t h e r a p y sessions.  It  the  no 'true  Considered  i n t h i s d i a g n o s i s was how w e l l a sense of f e m i n i n e i d e n t i t y was i n t e g r a t e d (in the case  of  a  biological  frustration, and  male)  as  well  to ' b i d e t i m e . '  as  Meyer  the  individual's  stated that  ability  to  deal  the c a n d i d a t e w i t h  with  the  best  prognosis was one w i t h a real u n d e r s t a n d i n g o f the d i f f i c u l t i e s to be f a c e d once t h i s t r a n s f o r m a t i o n was c o m p l e t e .  H e w e n t on to suggest that this u n d e r s t a n d i n g ,  c o m b i n e d w i t h a p e r s o n a l m a t u r i t y , m a y p o s s i b l y have been c o r r e l a t e d w i t h  the  s t a b i l i t y of the cross gender i d e n t i t y . In this p r o g r a m ( M e y e r , 1983) o n l y 5 % to 1 0 % o f c a n d i d a t e s a c t u a l l y opted for  the c o m p l e t i o n of  SRS.  Other reported  results i n c l u d e d : p e r m a n e n t passing  w i t h o u t s u r g e r y , or passing w h i l e w a i t i n g f o r i m p r o v e d s u r g i c a l t e c h n i q u e s ; l i v i n g (at  different  times)  as  both  sexes,  and  settling  on  neither;  resolution  of  the  d y s p h o r i a a n d p e r m a n e n t r e t u r n to the o r i g i n a l gender. E f f o r t s at the c r e a t i o n of a c o m m o n p s y c h o l o g i c a l p r o f i l e t h r o u g h  the use  of s u c h s t a n d a r d i z e d measures as the M i n n e s o t a M u l t i p h a s i c P e r s o n a l i t y I n v e n t o r y , C a l i f o r n i a P e r s o n a l i t y I n v e n t o r y a n d T h e m a t i c A p p e r c e p t i o n T e s t , have y i e l d e d no c o n s i s t e n t results ( W e a t h e r h e a d , et a l . , 1978).  Other efforts  at s e e k i n g c o m m o n  c h a r a c t e r i s t i c s across subjects suggest that the most o u t s t a n d i n g c h a r a c t e r i s t i c  of  people d i a g n o s e d as t r a n s s e x u a l is a n a r c i s s i s t i c w i t h d r a w a l to a c o n d i t i o n w h i c h is "dominated p.142).  by  submission and  T h i s was o b s e r v e d  p s e u d o - f e m i n i n i t y " (Sorenson  in conjunction  s e x u a l f e e l i n g s (Sorenson a n d H e r t o f t , 1982).  and  Hertoft,  w i t h a s u p p r e s s i o n of aggressive  1982, and  In a d d i t i o n to t h i s , the other c o m m o n  - 16 finding is that of lower self esteem scores compared with both heterosexual and homosexual groups (Ball, 1981; Skapec and Mackenzie, 1981). Walinder, Lundstrom, and Thuwe (1978) studied a mixed group (biological females and biological males) of fourteen post operative cases.  Five of these  individuals stated that they regretted having had the surgery, and therefore were considered as failures.  Walinder et al. hypothesized a series of factors, which if  present would act as contraindicators to surgery, and would therefore tend to be present in the background of the five subjects who stated regret at having been sex-reassigned. retardation,  The twelve unstable  factors  personality,  hypothesized alcoholism/drug  were:  psychosis,  addiction,  mental  criminality,  inadequacy of self-support, inadequate support from family, excessive geographical distance between patient and therapist, inappropriate physical characteristics to new gender role, completion of military service, heterosexual experience and strong sexual interest (p. 17-18).  A review of the backgrounds of the five individuals  stating regret showed an average of 7.8 of the hypothesized items (median score: 7.0).  The group of nine cases who reported being pleased at having had SRS  showed an average of 2.8 of these factors (median score: 2.0). This difference was statistically  significant (p< .02).  Reasons  for this  difference  were  highly  speculative.  The authors reported however, that with the exception of psychosis  and mental retardation, the presence of these factors may have resulted in some ambivalence toward the reassignment and hence caused lower levels of satisfaction with the outcome.  Though not originally hypothesized, Walinder et al. also stated  that the dissatisfied group was significantly older at the time of request than was the satisfied group.  In spite of the results being based on a small (and mixed)  sample, the authors suggested that the greater the number of these factors present (including age), the greater the likelihood of dissatisfaction after surgery, and hence cause for restraint in embarking upon a course of sex-reassignment.  - 17 A s c a n be seen f r o m the p r e c e d i n g d i s c u s s i o n , the issue of c l a s s i f i c a t i o n a n d d i a g n o s i s is s t i l l p r o b l e m a t i c .  B a l l (1981), i n d e s c r i b i n g his e x p e r i e n c e of w o r k i n g  w i t h t r a n s s e x u a l s o v e r the past t h i r t y years, suggested that it appears that issue has become more c o m p l i c a t e d r a t h e r t h a n less so.  this  In his o r i g i n a l w o r k i n the  m i d 1950's, the m a j o r i t y o f people r e q u e s t i n g s e x - r e a s s i g n m e n t a p p e a r e d h o m o g e n e o u s as c o m p a r e d w i t h the p r e s e n t i n g p o p u l a t i o n t o d a y .  relatively  He characterized  t h e m as b e i n g o f a b o v e a v e r a g e i n t e l l i g e n c e , e x t r e m e l y d e t e r m i n e d to c o m p l e t e the process, a n d w i t h " h i g h p e r s o n a l a s p i r a t i o n s w h i c h were t h w a r t e d by t h e i r personal d i f f i c u l t i e s " (p. 40).  U s i n g the T e r m a n M i l e s ' A t t i t u d e Interest S c a l e ' the subjects  scored h i g h e r on f e m i n i n e interest scales t h a n d i d a m a t c h e d g r o u p of w o m e n . his a r t i c l e , B a l l p o i n t e d out that at that t i m e , v e r y l i t t l e of the w o r k  In  i n this area  had been p u b l i s h e d by the p o p u l a r press, w i t h the e x c e p t i o n s o f the J o r g c n s o n a n d C o w e l l cases, w h i c h  h a d just r e c e n t l y  g r o u p as b e i n g l a r g e l y s e l f - s e l e c t i n g .  been r e p o r t e d .  He  described  this  initial  A s the study of t r a n s s e x u a l i s m a n d S R S has  i n c r e a s e d i n the p u b l i c consciousness, the p a t i e n t p r o f i l e r e q u e s t i n g s u r g e r y  has  become more heterogeneous r a t h e r t h a n homogeneous.  R e s e a r c h on E t i o l o g y The  issue o f c l a s s i f i c a t i o n is i n t r i n s i c a l l y l i n k e d w i t h e f f o r t s to establish  cause/etiology  treatment outcome).  Reported  i n c i d e n c e o f w h a t w o u l d a p p e a r to be t r a n s s e x u a l i s m has been r e c o r d e d  throughout  history  of  (Steiner  the s y n d r o m e  1981).  Early  (as w e l l as w i t h  theorists  hypothesized  that  the  cause  of  the  p h e n o m e n o n l a y i n some f o r m o f p a t h o g e n i c r e l a t i o n s h i p between m o t h e r a n d son. M o d e r n r e s e a r c h has not s u p p o r t e d t h i s h y p o t h e s i s ( B u h r i c h a n d M c C o n a g h y , 1978). T h e s e e a r l y theories f o c u s e d on b i o l o g i c a l males, due to the b e l i e f that they the great  majority,  if  not the t o t a l p h e n o m e n o n .  Statistics now  show  that  were the  d i s p a r i t y b e t w e e n males a n d f e m a l e s d i a g n o s e d as t r a n s s e x u a l is s h r i n k i n g (Olcs,  - 18 1977).  A c o m m o n f i n d i n g , c u r r e n t l y i n the r e s e a r c h , relates not so m u c h to the role  o f the m o t h e r but r a t h e r , to the absence, i n a b i l i t y or d i s i n t e r e s t of the f a t h e r  to  f u n c t i o n a d e q u a t e l y w i t h i n the p a t e r n a l role ( B e r n s t e i n , et. a l . , 1981; B u r i c h a n d M c C o n a g h y , 1978; S i p o r a a n d B r z e c k , 1983; S t o l l e r , 1979). In  addition  to i n v e s t i g a t i o n s  which could conceivably  which  have s t u d i e d  psychological  dynamics  result i n the d e v e l o p m e n t of the t r a n s s e x u a l  syndrome,  i n v e s t i g a t i o n s h a v e also addressed possible b i o l o g i c a l f a c t o r s in the e t i o l o g y of this syndrome.  S t o l l e r (1964) suggested that some h i d d e n c o n s t i t u t i o n a l (i.e. b i o l o g i c a l )  f a c t o r must be present f o r the s y n d r o m e to u n f o l d .  T h i s f a c t o r m a y operate  in  c o n j u n c t i o n w i t h p s y c h o s o c i a l f a c t o r s present, but in S t o l l c r ' s e s t i m a t i o n , the latter (the p s y c h o s o c i a l f a c t o r s ) , i n a n d of  themselves, w i l l not p r o d u c e  T h i s c o n c e p t was the result of his s t u d y of c r o s s - g e n d e r  the  syndrome.  i d e n t i t y , presented in a  s m a l l n u m b e r of intersexes ( h e r m a p h r o d i t e s a n d p s e u d o - h e r m a p h r o d i t e s ) .  Hocnig  (1985), i n his r e v i e w of the research i n t o b i o l o g i c a l antecedents p o i n t e d out Stoller's notions  of  the  importance of  M o n e y , H a m p s o n a n d H a m p s o n (1957).  the b i o l o g i c a l  factor  were  supported  that by  H o e n i g , in his e x p l i c a t i o n of t h e i r r e s e a r c h ,  stated that it s u p p o r t e d the p o s i t i o n of a ' n e u t r a l i t y ' o f gender i d e n t i t y at b i r t h . Money,  Hampson and  identity  Hampson  took p l a c e t h r o u g h  conditioning,  is g e n e t i c a l l y  (1957) a r g u e d  the process of fixed  that  the  imprinting.  development  of  gender  Since i m p r i n t i n g , unlike  a n d s p e c i e s - s p e c i f i c , the  formation  of  gender  i d e n t i t y is t h e n a n issue of a g e n e t i c a l l y i n h e r i t e d p r e d i s p o s i t i o n w h i c h is released or t r i g g e r e d  by c e r t a i n  p s y c h o s o c i a l events  which occur  in the presence of  the  individual. Hoenig  (1985)  showed  that  there  is  anecdotal  evidence  suggesting  e p i l e p s y w i t h a c c o m p a n y i n g t e m p o r a l lobe lesions o c c u r s more f r e q u e n t l y t r a n s s e x u a l s t h a n i n other s u b - g r o u p s of the p o p u l a t i o n . such  reports  were  highly  tentative  and  their  in  that the  H o e n i g a c k n o w l e d g e d that  significance  was  (and  remains)  - 19 unclear.  H o e n i g a n d K e n n a (1979), s t u d y i n g the E E G  transsexuals  (35 m a l e a n d  11 f e m a l e ) , d i d  patterns i n a d i s p r o p o r t i o n a t e l y  patterns of a g r o u p of 56  conclude  that  Hoenig  was not n e c e s s a r i l y consistent w i t h other  acknowledged EEG  in the t e m p o r a l  E x p l a n a t i o n s f o r the i n c o n s i s t e n c y of these f i n d i n g s as w e l l as f o r their  s i g n i f i c a n c e to the e t i o l o g y o f the s y n d r o m e are not f o r t h c o m i n g as yet. p o i n t e d out, despite the i n c o n s i s t e n c y  Walinder,  clear  research ( w h e n  a b n o r m a l i t i e s have been r e p o r t e d , they have not a l w a y s c e n t e r e d  levels o f  abnormal  In a p p r o x i m a t e l y 5 0 % of these cases the  a b n o r m a l i t y was i n e i t h e r the l e f t or r i g h t t e m p o r a l area.  lobe area).  were  large segment of the subjects (48% s h o w e d  a b n o r m a l i t i e s w h i l e 2 4 % were b o r d e r l i n e ) .  that this f i n d i n g  there  abnormality  have  1965; B l u m e r ,  and Kenna,1979).  now  i n i n c i d e n c e of E E G  been  reported  1969; R a n d c l l ,  As Hoenig  abnormality,  across a v a r i e t y  of  1970; K o c k o t t a n d N u s s c l t ,  elevated  studies  (e.g.  1976; H o e n i g  T h i s is an issue, H o e n i g says, w h i c h w i l l have to be a c c o u n t e d  for in future theoretical formulations. A t t e n t i o n has been f o c u s e d on other areas of the b r a i n as w e l l , in an e f f o r t to d i s c o v e r a b n o r m a l i t i e s w h i c h c o u l d e x p l a i n the d e v e l o p m e n t of  transsexualism.  T h e s e i n c l u d e s t u d i e s o f h o r m o n a l i m b a l a n c e s r e s u l t i n g i n m a l d c v e l o p m c n t i n the h y p o t h a l m i c r e g i o n ( N e u m a n n , 1970). an  androgen  deficiency  during  development, resulting in what states  that  given  differentiated  certain  brain,  the  A n o t h e r stream of research has f o c u s e d on  the  and  third  trimester  is d e s c r i b e d as a " f e m i n i z e d " b r a i n .  environmental result  second  is the  triggers  in  development  conjunction of  of  This  with  transsexualism  fetal theory  this  sex-  (Dorner,  R o h d e , S e i d e l , H a a s , a n d S c h o t t , 1976).  H o e n i g (1985), in his r e v i e w of these two  studies, pointed  were  out  that both  theories  based on results e x t r a p o l a t e d  a n i m a l s t u d i e s , w h i c h leave them open to some q u e s t i o n .  from  C o m m e n t i n g on the latter  of the two s t u d i e s , he stated that the existence of a s e x - d i f f c r e n t i a t c d  brain  in  - 20 h u m a n s has n e v e r been d e m o n s t r a t e d to exist.  O v e r a l l he expressed g r a v e doubts  that gender i d e n t i t y c o u l d be u n d e r s t o o d by o b s e r v i n g b e h a v i o r a l t r a i t s in a n i m a l s . H o e n i g (1985) goes i n t o some d e t a i l on the research of E n g c l , P f a f f l i n , and W i e d e k i n g (1980) on the f r e q u e n c y of H - Y female transsexuals.  Engel  a n t i g e n a b n o r m a l i t i e s i n b o t h male a n d  et a l . (1980) have  reported  the o c c u r r e n c e  a n t i g e n a b n o r m a l i t i e s i n a s i g n i f i c a n t n u m b e r of t r a n s s e x u a l s s t u d i e d .  of  H-Y  H-Y  antigen  has been s h o w n to be s i g n i f i c a n t i n the e s t a b l i s h m e n t of sex. A s yet h o w e v e r , these researchers are not a b l e to o f f e r a n y d o c u m e n t e d r a t i o n a l e f o r  the role of  H-Y  a n t i g e n i n the d e v e l o p m e n t o f gender i d e n t i t y . A s this shows,  there  statements o f  brief exist  review some  of  some of  interesting  the  early  representative findings,  but  studies as  yet  in no  this  area  conclusive  b i o l o g i c a l , p s y c h o l o g i c a l or i n t e r a c t i v e p a t h w a y s of e t i o l o g y may be  made.  R e s e a r c h on T r e a t m e n t  Outcome  L o t h s t e i n (1980) s t u d i e d 21 b i o l o g i c a l male t r a n s s e x u a l s w h o had c o m p l e t e d s e x - r e a s s i g n m e n t s u r g e r y . G r o u p I c o m p l e t e d the s u r g e r y p r i o r to the o r g a n i z a t i o n of  the  Case  G r o u p II  Western  Reserve  University  (CWRU)  Gender  h a d s u r g e r y a f t e r the c r e a t i o n of the c l i n i c .  Identity  Clinic,  T h e services of the c l i n i c  were t w o - f o l d : to p r o v i d e an intense i n t e r d i s c i p l i n a r y e v a l u a t i o n of each and  to  surgery.  provide In  ongoing  the two  year  psychotheraputic follow-up  after  support  prior  S R S , 57% of  to,  during  Group  I who  e m p l o y e d p r i o r to s u r g e r y , were u n e m p l o y e d i n the f o l l o w - u p p e r i o d . also a c o m m o n theme o f s o c i a l i s o l a t i o n , a n d at best o n l y with  people.  consequently  The not  nonetheless, G r o u p  follow-up all II  of  the  showed  procedures results  for  were  Group  II  directly  a 65% improvement  in  and  patient  and had  after been  T h e r e was  marginal relationships  were  more  comparable work  detailed to  Group  and 1;  a d j u s t m e n t , 2 9 % no  - 21 c h a n g e a n d 7% s h o w e d a n e g a t i v e change.  In terms of r e l a t i o n s h i p s there was no  evidence of s i g n i f i c a n t positive improvement in social relationships. first  group,  they  tended  to be s o c i a l l y  s a t i s f a c t i o n , patients i n G r o u p i d e n t i t i e s a n d the a d e q u a c y incidents surgery  isolated.  of  their  recurrent  images of  (the  duration  of  the  genitals.  'phantom  study).  A  this.  Among  this  There  group,  f u l l 5 0 % of  penises' up were  sensations d e s p i t e the p h y s i o l o g i c a l e v i d e n c e (the of  reports  of  subjective  II e x h i b i t e d m u l t i p l e f e a r s s u r r o u n d i n g  of  impossibility  Despite  A s w i t h the  to  also  there  were  patients  two  years  reports  of  r e m o v a l of  their  reported following  ejaculatory  male tissue) of  also  reports  new  of  the  episodic  d e p r e s s i o n a n d t h o u g h t s of s u i c i d e ( t h o u g h no a c t u a l s u i c i d e s o c c u r r e d d u r i n g the time o f the s t u d y ) .  L o t h s t e i n reported  that there were  s t r u c t u r e or p s y c h i a t r i c d i a g n o s i s i n e i t h e r p o s t - s u r g e r y  no changes in c h a r a c t e r group.  B c h a v i o r a l l y , he  r e p o r t e d that i n the post o p e r a t i v e p e r i o d less s t e r e o t y p i c a l r e c r e a t i o n a n d s o c i a l a c t i v i t i e s were engaged i n . Though  the  lack of  results f r o m G r o u p II, overall  improvement  difficult  a control  which  acknowledged  rate  of  requirements  factors  that of  limited  the g e n e r a l i z a b i l i t y  of  the  L o t h s t e i n (1980) suggested that in this s t u d y there was an approximately  to separate the e f f e c t s of  revealing  group  this  had was  a gender  65%.  SRS from  resulted  in  identity  program,  d i f f e r e n t f r o m those i n d i v i d u a l s w h o w o u l d  pointed  the e f f e c t s of  the  a self-selecting  He  who  may  rate.  would  have  that  it  psychotherapy  improvement  group and  out  He  submit  been  to  was in also the  significantly  have chosen to go t h r o u g h a p r i v a t e  p r a c t i t i o n e r w h o w o u l d not place the same r e q u i r e m e n t s on t h e m . Though dimensions,  the  Lothstein's findings  (1980) results remained  demonstrated  somewhat  mixed  improvement when  on  contrasted  specific with  the  s u b j e c t i v e r a t i n g s o f post o p e r a t i v e s a t i s f a c t i o n by those i n d i v i d u a l s i n v o l v e d , a l l of w h o m r e p o r t e d b e i n g e x t r e m e l y s a t i s f i e d .  N o t i n g this, Lothstein cited previous  - 22 f i n d i n g s d e m o n s t r a t i n g an 8 0 % s o c i a l - p s y c h o l o g i c a l i m p r o v e m e n t f o l l o w i n g s u r g e r y (Benjamin,  1966; R a n d a l l ,  1969).  Lack  of  standardization  in  rating  procedures  a p p e a r e d to be one o f the f a c t o r s i n these c o n f l i c t i n g results. H u n t a n d H a m p s o n (1980), i n a study of post o p e r a t i v e p a t i e n t s (mean of 8.2 years), c o u l d d e m o n s t r a t e no s i g n i f i c a n t changes i n levels of p s y c h o p a t h o l o g y only  modest  gains  relationships.  in  terms  of  economic  functioning  and  and  interpersonal  M o r e s t r i k i n g changes ( p o s i t i v e ) o c c u r r e d i n s e x u a l s a t i s f a c t i o n a n d  f a m i l y acceptance.  The  i n c l u s i o n of  subjects  demonstrating  psychopathology  in  this s t u d y s t r o n g l y l i m i t s its c o m p a r a b i l i t y w i t h the p r e v i o u s l y c i t e d w o r k , yet one may suggest  that the e x i s t e n c e or  non-existence  of p s y c h o p a t h o l o g i c a l  symptoms  p r i o r to s u r g e r y is not s i g n i f i c a n t l y a f f e c t e d by S R S . F l e m i n g , C o h e n , S a l t , Jones, a n d J e n k i n s (1981) f o u n d a s i g n i f i c a n t l y level  of  psychological  functioning  (MMPI  scores)  c o m p a r e d w i t h t e s t i n g i n p r e - o p c r a t i v e periods.  in  post  operative  higher  subjects,  T h e a u t h o r s d i d not suggest  this result that S R S is c a p a b l e of c u r i n g s y m p t o m s of m e n t a l i l l n e s s , but may have a p o s i t i v e e f f e c t on n o n - p s y c h o p a t h o l o g i c a l Attempts  have  been  made  to  introduce  the  already  mentioned  issue  of  the  a standardized  rating  inclusion  of  procedures,  psychopathology, and  current  sexual  family  adjustment,  subjects  reactions)  commonness in rating and f o l l o w - u p .  begin  additional to  address  system  1980).  psychopathological symptoms, their dimensions for fating (economic, relationships,  rather,  functioning.  investigate pre- and post-surgical adjustment (Hunt and Hampson of  from  to  In spite exhibiting  interpersonal  surgeries the  need  and for  T h i s broader f o c u s in r a t i n g s u c c e s s / f a i l u r e ,  is also i m p o r t a n t i n terms of a move a w a y f r o m the n a r r o w f o c u s o f solely m e d i c a l a n d / o r p s y c h o l o g i c a l assessments f o r i n t e r v e n t i o n , t r e a t m e n t a n d e v a l u a t i o n . Hastings  and  Markland  (1978),  t r a n s s e x u a l s as p a r t of a ten year s t u d y ,  tracked  twenty-five  male-to-femalc  T h e y also o f f e r e d a scheme f o r assessing  - 23 p o s t - s u r g i c a l success.  R a t i n g on f o u r  dimensions: social, emotional, sexual  e c o n o m i c , each d i m e n s i o n was scored as e x c e l l e n t , g o o d , f a i r or poor.  and  R e p o r t i n g at  the m i d - p o i n t o f the s t u d y ( f i v e years post o p e r a t i v e l y ) , they f o u n d that consistent with  other  f i n d i n g s , the subject  population unanimously  pleased at h a v i n g c o m p l e t e d the process of S R S .  agreed  that  they  were  I m m e d i a t e post o p e r a t i v e results  i n c l u d e d a sense o f r e l i e f at " f i n a l l y b e i n g a w o m a n , " s u r p r i s e at the degree  of  p o s t - s u r g i c a l p a i n , a n d interest i n m a m m a p l a s t y a n d c a r t i l a g e s h a v i n g of the a d a m s apple.  N o post o p e r a t i v e d e l i r i u m , p s y c h o t i c r e a c t i o n s or o c c u r r e n c e s of ' p h a n t o m  penises' were w i t n e s s e d i n this g r o u p . not r e p o r t e d , other rating  were  t h a n to say that subjects  characterized  structures prior  U n f o r t u n a t e l y , the l o n g e r - t e r m results were  to s u r g e r y "  as  having  (p. 33).  "high  w h o rated an o v e r a l l sociopathic  loading  poor  of  to  fair  personality  H a s t i n g s and M a r k l a n d stated that in  their  s a m p l e the area of r o m a n c e p r o v e d to be the most d i f f i c u l t a n d p r o b l e m a t i c to post o p e r a t i v e a d j u s t m e n t ( w h e t h e r o v e r a l l h i g h or low ratings).  T h i s m a y be consistent  w i t h a p r e v i o u s l y c i t e d s t u d y ( L o t h s t e i n , 1980) w h i c h stressed the c h a r a c t e r i s t i c of social isolation.  Some studies s h o w i n g i m p r o v e d s o c i a l a d j u s t m e n t  (VVeatherhcad,  D i x o n , et a l . , 1978) were f o u n d to be vague i n t h e i r d e f i n i t i o n o f ' i m p r o v e d s o c i a l adjustment.' T h e s i n g l e most i n f l u e n t i a l a n d c o n t r o v e r s i a l research project o f the 1970's has c o m e to be k n o w n  as "The  "Johns H o p k i n s G e n d e r  I d e n t i t y C l i n i c a n d C o m m i t t e e " was e s t a b l i s h e d in 1965,  h a v i n g dealt  with  Hopkins Report" (Meyer  transsexual patients for  the p r e v i o u s  and Retcr,  five  years.  1979).  The  Meyer  and  R e t e r (1979) began the s t u d y i n 1971 i n an a t t e m p t to " . . . step back f r o m the n o r m a l i z a t i o n of sex-reassignment procedures in order  to look o b j e c t i v e l y  at the  l o n g - r a n g e e f f e c t s of s u r g e r y " (p. 1010). B e g i n n i n g w i t h 34 o p e r a t e d a n d 66 u n o p e r a t c d p a t i e n t s the researchers set out  to assess ( u s i n g  primarily  interviews)  the  functioning  of  operated  subjects  -24before and after  surgery.  Though  not a s t r i c t ' c o n t r o l  s a m p l e o f f e r e d some basis f o r c o m p a r i s o n .  group,'  the  unoperated  D u r i n g the d a t a c o l l e c t i o n p e r i o d (three  years) a t h i r d g r o u p e m e r g e d : subjects w h o were o p e r a t e d on d u r i n g the course of the s t u d y .  Ultimately,  52 i n t e r v i e w s  were  c o m p l e t e d , across  the  F o l l o w - u p scores were c a l c u l a t e d (based on c o n c r e t e b e h a v i o r s ) dimensions: legal, economic, marriage/cohabitation and  three  groups.  on each of  psychiatric.  From  four these  d i m e n s i o n scores, an o v e r a l l change score f o r each subject, a n d mean c h a n g e scores f o r each g r o u p were c a l c u l a t e d . T h e results s h o w e d that there was a p o s i t i v e s h i f t o v e r a l l f o r each of three g r o u p s , a c c o m p a n i e d by  a narrowing  scores, b e t w e e n g r o u p s , were not s i g n i f i c a n t .  of  standard deviations.  The  the  change  C h a n g e scores f o r o p e r a t e d p a t i e n t s  (those o r i g i n a l l y tagged as o p e r a t e d as opposed to those w h o s u b s e q u e n t l y became 'operated')  were  s i g n i f i c a n t change  not  significant  (p<1.0).  scores (p<.001).  The  Unoperated  subsequently  worst o f the three i n o v e r a l l change ( m e a n , -0.4).  patients  operated  did  group  achieve fared  the  T h e a u t h o r s c o n c l u d e d that S R S  r e s u l t e d i n no o b j e c t i v e a d v a n t a g e in terms of s o c i a l r e h a b i l i t a t i o n , as measured by the f o u r d i m e n s i o n s used.  T h e passage o f t i m e w o u l d a f f e c t i m p r o v e m e n t in the  s o c i a l f u n c t i o n i n g o f these i n d i v i d u a l s where the i n t e r v e n t i o n of S R S w o u l d not. A b r a m o w i t z (1986), i n r e v i e w i n g the last two decades o f e m p i r i c a l w o r k  in  the a r e a o f o u t c o m e o f s e x - r e a s s i g n m e n t s u r g e r y , d e v o t e d a s e c t i o n o f his r e v i e w to the  Hopkins  Report  and  the  c r i t i c i s m s of  it.  Citing  F l e m i n g , S t e i n m a n , and  B o c k n e c k (1980), he q u e s t i o n e d the a r b i t r a r i n e s s of the o u t c o m e categories.  For  e x a m p l e , l i v i n g a l o n e was c o n s i d e r e d less a d j u s t e d t h a n l i v i n g w i t h someone.  It is  also w o r t h n o t i n g that the m a r i t a l / c o h a b i t a t i o n d i m e n s i o n j u d g e d of the p a r t n e r ' s (spouse's) gender.  appropriateness  F o r e x a m p l e , f o r a post o p e r a t i v e m a l c - t o - f e m a l c  t r a n s s e x u a l to be j u d g e d  as s u c c e s s f u l on this d i m e n s i o n , the p a r t n e r  male.  then  The  couple  were  viewed  as l i v i n g  in an ' a p p r o p r i a t e '  would  be  heterosexual  -25relationship. relationship, relationship.  The  post o p e r a t i v e  appears  to  have  individual  been  judged  living as  with  having  a w o m a n , in a lesbian a  'gender  inappropriate'  F l e m i n g et a l . (1980) w e n t on to note that e a c h d i m e n s i o n had a  different  number  of  response  therefore  causing different  categories  components  and  different  to have  unequal  possible  score  ratings.  ranges,  Basing  their  d e d u c t i o n s on possible score ranges a n d a c t u a l r e p o r t e d means, F l e m i n g et a l . made a c o n v i n c i n g case that c e r t a i n n e g a t i v e events f i g u r e d c u m u l a t i v e l y but that duration  of  events  were  ignored.  Examples  of  the  r a m i f i c a t i o n s of  this  the were  s u p p l i e d by the a u t h o r s : t w o arrests were worse t h a n one ( d i s r e g a r d i n g the s e v e r i t y of the charges); two h o s p i t a l i z a t i o n s were worse t h a n one w h a t e v e r  the d u r a t i o n s  o f the h o s p i t a l i z a t i o n s m i g h t have been. A b r a m o w i t z (1986) stated that i f F l e m i n g et a l . (1980) were c o r r e c t in their d e d u c t i o n s , the c o n f o u n d of d i f f e r e n t lengths of time f o r f o l l o w - u p (an average of 5  years  in  significant.  the  operated  group  and  2  years  for  the  unopcrated  group)  was  If the n e g a t i v e events were w e i g h t e d c u m u l a t i v e l y , then the longer the  f o l l o w - u p p e r i o d , the more o p p o r t u n i t y  to amass n e g a t i v e p o i n t s , so to speak.  went on to express a m a z e m e n t that such an e l e m e n t a r y p s y c h o m e t r i c e r r o r have escaped both the a u t h o r s a n d the o r i g i n a l r e v i e w e r s . H e c o n c l u d e d  He  could  however,  that it d i d a p p e a r that the c a l c u l a t i o n s of the H o p k i n s R e p o r t were biased against the p r i m a r y s u r g i c a l g r o u p a n d t h e r e f o r e the f i n d i n g s were m i s l e a d i n g . A b r a m o w i t z (1986) d i d not save his m e t h o d o l o g i c a l c r i t i c i s m s f o r the H o p k i n s R e p o r t .  Resulting  exclusively  f r o m his r e v i e w o f this body o f l i t e r a t u r e , he  stated that d e p a r t u r e s f r o m the u s u a l s c i e n t i f i c p r o c e d u r e s were a l l too  frequent.  A s a n e x a m p l e he noted that c o n t r o l groups were an i n n o v a t i o n i n t r o d u c e d o n l y in the p r e v i o u s  f i v e years.  W i t h o u t the use of  rigorous control groups,  e i t h e r success or d e t e r i o r a t i o n to the i n t e r v e n t i o n scientifically indefensible.  attributing  of s e x - r c a s s i g n m e n t s u r g e r y  is  T h o u g h f r u s t r a t e d , he also expressed s y m p a t h y w i t h the  - 26 difficulty  and  sometimes  impossibility  of  creating  these  control  groups.  He  expressed less s y m p a t h y w i t h other p r a c t i c e s d i s c o v e r e d i n the l i t e r a t u r e .  We are  typically  left  in  the  dark  about  such  obviously  critical  subject  v a r i a b l e s as p s y c h i a t r i c status a n d d i a g n o s i s , extent of gender r e o r i e n t a t i o n , and  previous  subsequent  early-stage  reports  by  sex-change  procedures.  the same i n v e s t i g a t o r  Subjects  included  sometimes a p p e a r to  in  overlap  w i t h samples f r o m e a r l i e r series. I n c r e d i b l y , subjects w h o c o m m i t t e d s u i c i d e are  occasionally  not  included  in  computation  of  the  because they were not a v a i l a b l e f o r f o l l o w - u p . . . .  improvement  The  rate  research is r i f e  w i t h v i o l a t i o n s of g e n e r a l l y a c c e p t a b l e assessment p r a c t i c e s , (p. 184)  Abramowitz quantitativc  divided  the  and quantitative.  research  into  two  methodological  groups:  prc-  O u t c o m e reports in the p r c - q u a n t i t a t i v e studies (10  s t u d i e s r e v i e w e d ) s h o w e d that 6 0 % to 8 5 % of p a t i e n t s were rated as i m p r o v e d or satisfied.  A  t o t a l of  14 serious c o m p l i c a t i o n s ( d e f i n e d  as a r e v e r s a l  request, a  p s y c h o t i c e p i s o d e , h o s p i t a l i z a t i o n , or s u i c i d e ) were r e p o r t e d in the ten studies (6.4% of  the  total  subjects).  The  strongest  positive  results  were  on  dimensions  of  cosmetic satisfaction, interpersonal relationships and psychological well-being.  Less  pronounced  and  improvement  was  reported  i n areas of  work,  e c o n o m i c s , legal  sexual relationships. In r e v i e w i n g these s t u d i e s , A b r a m o w i t z (1986) c a u t i o n e d the reader that this b o d y o f r e s e a r c h d i d not i n c o r p o r a t e  psychometric  instruments, and  the a u t h o r s h a d s i g n i f i c a n t p e r s o n a l i n v e s t m e n t s in the o u t c o m e s . note, he a d d e d that  the results were s t r e n g t h e n e d  v a r i a b l e s a n d p o t e n t i a l patient m e d i a t o r s " (p. 185).  by " w e l l  On  universally, a positive  articulated  outcome  W i t h o u t c o n t r o l groups, we arc  - 27 u n a b l e to d r a w c a u s a l r e l a t i o n s h i p s between b a s e l i n e a n d o u t c o m e d a t a  a n d the  effect of S R S . The  quantitative  standardized section.  rating  The  studies  scales.  average  A  incorporated  psychometric  inventories  and  reviewed  this  total of  fourteen  studies  were  period  was f o u r  years.  R e s u l t s of  follow-up  in  the  studies  e m p l o y i n g l o n g i t u d i n a l f o l l o w - u p w i t h o u t the use of a c o n t r o l g r o u p s u p p o r t e d earlier  pre-quantitative  approximately  research  two-thirds  (a  and  range  showed  from  an  average  5 0 % to  improvement  85%).  Of  the  the  rate  three  of  quasi-  e x p e r i m e n t a l studies r e p o r t e d ( F l e m i n g , et a l . , 1981; F l e m i n g , M a c G o w a n , R o b i n s o n S p i t z & S a l t , 1982; M e y e r a n d R e t e r , 1979) t w o of the three r e p o r t e d i m p r o v e m e n t s i n the s u r g i c a l g r o u p (the t h i r d study M e y e r a n d R e t c r , 1979).  A sin g le s t u d y  significant  was the p r e v i o u s l y  discussed  based on q u a n t i f i e d R o r s h a c h  responses  s h o w e d e q u i v o c a l results ( F l e m i n g , Jones & S i m o n s , 1982). T a k e n as a g r o u p , the q u a n t i t a t i v e studies r e p o r t e d the greatest gains in the areas  of  sexual  previously  satisfactions  and  relationships  (though  c i t e d , c o u l d d e m o n s t r a t e no s i g n i f i c a n t  a  minority  improvement  in  of  studies,  relationships).  Less i m p r o v e m e n t  was made i n s o c i o e c o n o m i c areas a n d i n c o s m e t i c results.  lack  cosmetic  of  gains  research  and  Abramowitz  in  is c o n f u s i n g suggested  that  results in  conflicts  light  this  of  result  with  surgical may  the  earlier  advances  be d u e  of  The  (prc-quantitativc) this  time  period.  less to the c o s m e t i c  results  t h e m s e l v e s , a n d more to the l a c k o f s t a n d a r d i z a t i o n i n m e a s u r i n g it. In d i s c u s s i n g the v a r i a b l e s w h i c h group  of  studies  quantitative), prognosis. other  that  (quantitative), character  m a y m e d i a t e o u t c o m e , this more  clearly  pathology  supported  is a  negative  the  earlier  factor  in  recent  finding post  operative  W a l i n d c r ct a l . (1978), as m e n t i o n e d b e f o r e , d e m o n s t r a t e d e v i d e n c e  negative  factors,  including:  inadequate  family  support,  criminal  o l d e r p a t i e n t s , i n a p p r o p r i a t e p h y s i q u e , a n d i n a d e q u a t e self s u p p o r t .  (pre-  for  records,  - 28 Abramowitz  (1986) closed his r e v i e w  of  the last t w o  decades of  outcome  research by s a y i n g :  R e s e a r c h is m e r e l y h u m a n b e h a v i o r , no more a n d no less, a n d e v e r y bit as subject to p e r s o n a l w h i m s a n d c o m m i t m e n t s .  One  can  even look on the f a i l u r e to i n c o r p o r a t e p r o p e r c o n t r o l s as m o t i v a t e d forgetting,  in  the  service  of  retaining  personal  control  over  the  u l t i m a t e i n t e r p r e t a t i o n o f the results.  P e r h a p s the absence of c o n t r o l  groups need not be v i e w e d so h a r s h l y .  A f t e r a l l , they are i m p r a c t i c a l  (and so me t ime s u n e t h i c a l )  in addition  to b e i n g i n c o n v e n i e n t .  The  f a i l u r e to f o l l o w reasonable assessment p r a c t i c e s , w h i c h are r e l a t i v e l y s i m p l e to a s c e r t a i n , seems less e a s i l y u n d e r s t o o d w i t h o u t i n v o k i n g the n o t i o n of ego i n v o l v e m e n t . After  three  decades of  case h i s t o r i c a l , p r e q u a n t i t a t i v c ,  and  q u a n t i t a t i v e research on the outcome o f s e x - r e a s s i g n m e n t s u r g e r y , we h a v e yet to see e i t h e r the r e p l i c a t i v e use of s t a n d a r d i z e d assessment d e v i c e s to f a c i l i t a t e c r o s s - s t u d y c o m p a r i s o n or the d e v e l o p m e n t of a multidimensional  inventory  to  postsurgical rehabilitation . . . . state-of-the-art  tap  the  various  sub-domains  T h i s c o l l e c t i v e r e l u c t a n c e to  methods to bear on the d i f f i c u l t  treatment  of  bring  decision  becomes less p e r p l e x i n g , h o w e v e r , w h e n we have recourse to s c i c n t i s t a s - p e r s o n v a r i a b l e s i n our m o d e l o f the d e v e l o p m e n t  o f a research  l i t e r a t u r e , (p.188-189)  In t h i s r e v i e w  of the l i t e r a t u r e on t r a n s s e x u a l i s m , w h a t  has emerged is a  series of e m p i r i c a l studies w h i c h have a t t e m p t e d to f o c u s p r i m a r i l y on three areas: c l a s s i f i c a t i o n , etiology and treatment outcome. e t i o l o g y a n d t r e a t m e n t a p p e a r to be f r e q u e n t l y  T h e results o f w o r k i n the areas of inconsistent and c o n f l i c t i n g .  The  - 29 c l a s s i f i c a t i o n schemas are yet to be t r u l y s t a n d a r d a l t h o u g h there does a p p e a r to be a  general  goal  transsexual.  of  The  establishing studies of  a  working  post-surgical  definition follow-up  of  a  'primary'  to d e t e r m i n e  or  'true'  outcome  have  l a c k e d c o n s i s t e n c y of m e t h o d a n d a p p r o a c h ( L o t h s t e i n  1980, A b r a m o w i t z ,  w o u l d a p p e a r that these issues are h i g h l y i n t e r r e l a t e d .  L a c k of a g r e e m e n t i n areas  of  'cause'  and  classification  (psychological/psychosocial,  will  tend  medical  to  or  foster  both)  inconsistency and  in  1986). It  treatment  consequently  lead  to  i n c o n s i s t e n c y of f o c u s i n f o l l o w - u p . Oles  (1977)  psychotherapeutic  presented  a  discussion  of  to w o r k  with  issues p e r t a i n i n g  what  she  gender  While presenting  an o v e r v i e w  o f such  as  dysphoric  T h i s paper r e s u l t e d f r o m her c l i n i c a l e x p e r i e n c e at the " G e n d e r i n San F r a n c i s c o .  views  g en eral  individuals.  Identity Program"  landmark  research  as  C a l d w e l l (1947), she f o c u s e d p r i m a r i l y on v a r i o u s aspects of l i f e w h i c h i m p a c t on the i n d i v i d u a l .  Working  f r o m the a s s u m p t i o n o f  gender  identity  r e s i d i n g on a  c o n t i n u u m , a n d that s u r g e r y i n some cases is the best o p t i o n , Oles discussed the i m p a c t of f a m i l y , c o m m u n i t y , e m p l o y e r , a n d other f a c t o r s , on the people she has treated in therapy.  A t a more s p e c i f i c l e v e l , she spoke o f the i m p a c t o f  ' r e a d ' on the street ( r e c o g n i z e d  as a t r a n s s e x u a l )  being  b e i n g a r r e s t e d , c r o s s - d r e s s i n g at  w o r k , as w e l l as v a r i o u s responses f r o m f a m i l y , f r i e n d s a n d t h e r a p i s t s . Y a r d l e y (1976), i n r e v i e w i n g his w o r k w i t h t r a n s s e x u a l s , h y p o t h e s i z e d a c c e p t a n c e by the t h e r a p i s t of the p r e - o p e r a t i v e  that  t r a n s s e x u a l ' s d e s i r e f o r S R S may  be s i g n i f i c a n t i n s u c c e s s f u l post o p e r a t i v e a d a p t a t i o n . B o t h Y a r d l e y (1976) a n d Oles (1977) have addressed w h a t c a n be t e r m e d as 'contextual'  issues.  Yardley,  with  his  hypothesis  regarding  acceptance  by  the  t h e r a p i s t , a n d Oles i n her d i s c u s s i o n of the i m p a c t of the e m p l o y e r , the f a m i l y a n d the g e n e r a l p u b l i c , have both a c k n o w l e d g e d that the i n d i v i d u a l does not l i v e in a v a c u u m , but  rather,  must exist  and  interact  with  a variety  of  individuals  and  - 30 groups w h o a l l -to v a r y i n g  degrees- a f f e c t the i n d i v i d u a l .  To  a somewhat  lesser  e x t e n t this was also a c k n o w l e d g e d by W a l i n d e r et a l . (1978) w h o , i n t h e i r f o c u s on c o n t r a i n d i c a t o r s , l i s t e d ( a m o n g others): l a c k o f f a m i l y s u p p o r t , g e o g r a p h i c d i s t a n c e b e t w e e n the t h e r a p i s t a n d p a t i e n t , a n d l a c k of p e r s o n a l s u p p o r t .  Shumaker (Levine  a n d S h u m a k e r , 1978) r e c a l l e d her f r u s t r a t e d attempts to get a p p o i n t m e n t s w i t h the gender i d e n t i t y  clinic staff.  they f r e q u e n t l y  involved  professionals.  When a p p o i n t m e n t s were s e c u r e d , she r e p o r t e d  b e i n g i n t e r v i e w e d by u n k n o w n , a n d (to her),  anonymous  A t other times the a p p o i n t m e n t s consisted o f w r i t i n g test b a t t e r i e s ,  the purposes of w h i c h were not e x p l a i n e d . experiences  that  by  saying:  "Only  Kafka  post  operative  She f i n i s h e d her d e s c r i p t i o n of these  could  have  designed  such  a  torment  of  u n c e r t a i n t y " (p. 254). Mason  (1980),  a  female-to-male  transsexual,  told  of  the  g r a d u a l r e a l i z a t i o n of his t r a n s s e x u a l i s m a n d his e v e n t u a l e f f o r t s to become sexreassigned. common with  He  described  how,  beginning  at  puberty,  he  had  less a n d  less  in  other g i r l s yet because of his p o s i t i o n as a b i o l o g i c a l f e m a l e , was  u n a b l e to m a k e f r i e n d s h i p ties w i t h boys; l o n e l i n e s s a n d i s o l a t i o n became p r i m a r y themes. 1960's.  M a s o n then r e l a t e d his e x p e r i e n c e s i n s e e k i n g p r o f e s s i o n a l help d u r i n g the These i n c l u d e d meeting with: a church social worker  pray; a psychiatrist  w h o a d v i s e d h i m to  w h o b e l i e v e d he was d e l u s i o n a l ; a n e n d o c r i n o l o g i s t  that n o t i o n s o f s e x - r e a s s i g n m e n t  w h o said  were a b s u r d a n d that he s h o u l d get a j o b ;  and  f i n a l l y , a p s y c h i a t r i s t a n d gender i d e n t i t y team w h o d i a g n o s e d h i m as t r a n s s e x u a l a n d a c t i v e l y s u p p o r t e d his e f f o r t s to h a b i l i t a t e i n t o the new gender.  He  reported  that the t r e a t m e n t team's use of the male p r o n o u n w h e n r e f e r r i n g to h i m , a n d t h e i r r e f e r r i n g to S R S as " c o r r e c t i v e s u r g e r y , " a l l h e l p e d h i m i n his e f f o r t s  to a c h i e v e  w h a t he terms "self respect."  T h o u g h this is a h i g h l y s u b j e c t i v e a c c o u n t , the issues  raised are i m p o r t a n t  For  living,  disclosing  to  ones.  friends  e x a m p l e , the d i f f i c u l t i e s o f p r e - o p e r a t i v e and  colleagues,  accidental  meetings  with  crosspast  - 31 a c q u a i n t a n c e s , a n d the s h a r i n g of a c c o m m o d a t i o n w h e n t r a v e l l i n g , are a l l e x a m p l e s of w h a t c o u l d be t e r m e d c o n t e x t u a l issues. E m p i r i c a l w o r k o f this type (i.e. that w h i c h focuses on m e d i a t i n g f a c t o r s w h i c h exist process of  within  the e n v i r o n m e n t , as w e l l as i n t r a p s y c h i c a l l y , a n d a f f e c t  adaptation)  appears to be l a c k i n g  i n the p u b l i s h e d  literature.  the This  project has a t t e m p t e d to address this by v i e w i n g the i n d i v i d u a l not as a n isolated p h e n o m e n o n , but  r a t h e r , as one e m b e d d e d  within  a context.  The  "Ecological-  Systems M o d e l " w h i c h was chosen as a g u i d e f o r the c l a s s i f i c a t i o n o f these f a c t o r s , e m p h a s i z e d the i n t e r a c t i o n o f the i n d i v i d u a l a n d s u r r o u n d i n g systems. a system o f  classification which clearly  highlights  the e n v i r o n m e n t a l  It  provided influences  a c t i n g u p o n the i n d i v i d u a l . Extending  the w o r k  of  Yardley  (1976), Oles (1977), M a s o n (1980),  Lcvinc  a n d S h u m a k e r (1978), the s t u d y f o c u s e d on the s p e c i f i c i n c i d e n t s , e v e n t s , a t t i t u d e s , etc., o c c u r r i n g both p r e - a n d post o p e r a t i v e l y , w h i c h a f f e c t e d the i n d i v i d u a l ' s post o p e r a t i v e role a d j u s t m e n t . study  of  an  individual,  T h e case s t u d y a p p r o a c h a l l o w e d f o r a c o m p r e h e n s i v e hypotheses  generation  for  testing  with  p o p u l a t i o n , a n d a s t a r t i n g point to c o n s t r u c t a n d e n r i c h t h e o r y .  others  in  Ultimately  the it is  this t h e o r y w h i c h w i l l g u i d e c l i n i c i a n s i n t h e i r a t t e m p t s to i m p a c t most p o s i t i v e l y on the l i v e s o f t r a n s s e x u a l people.  -32-  CHAPTER  III  METHODOLOGY  T h e n a t u r e o f this s t u d y has r e q u i r e d the use o f q u a l i t a t i v e a n d case s t u d y methods. (with  The  both  instruments: McKinley,  d a t a c o l l e c t i o n has f o c u s e d h e a v i l y  retrospective The  and  Minnesota  current  foci)  Multiphasic  1967), the F a m i l y  in  on s e m i - s t r u c t u r e d  conjunction  Personality  with  Inventory  Assessment M e a s u r e ( S k i n n e r ,  interviews  standardized  (Hathaway  Steinhauer  and  & Santa-  B a r b a r a , 1984), a n d the S o c i a l S u p p o r t Q u e s t i o n n a i r e ( S a r a s o n , L e v i n e , B a s h a m & S a r a s o n , 1983).  The  d a t a a n a l y s i s , u t i l i z i n g the c r i t i c a l i n c i d e n t  t e c h n i q u e , has  r e s u l t e d i n a c l a s s i f i c a t i o n system based on an e c o l o g i c a l m o d e l o f systems. establish  interacting  T h e c l a s s i f i c a t i o n system was then s u b j e c t e d to f u r t h e r a n a l y s i s so as to a  distribution  displaying  the  critical  incidents  according  to  their  p e r c e i v e d levels o f s i g n i f i c a n c e .  The Case Study A l l p o r t (1962), c i t i n g G r a u r m a n n , states: " s h a l l o u r u n i t s o f a n a l y s i s i n the s t u d y of p e r s o n a l i t y be d e r i v e d f r o m g e n e r a l p s y c h o l o g i c a l c o n c e p t s or f r o m l i v e s as a c t u a l l y "horizontal"  l i v e d ? " (p. 409). (across  Allport  people).  He  goes on to d e s c r i b e t r a d i t i o n a l methods as "vertical"  to  d e s c r i b e those m e t h o d s w h i c h f o c u s on the i n d i v i d u a l a n d the u n d e r s t a n d i n g  of  one person r a t h e r t h a n m a n y . the  horizontal  individual?"  dimensions  uses  the  term  "morphogenic"  or  H e c h a l l e n g e s researchers to ask the q u e s t i o n :  (psychological  laws)  have  true  A s an e x a m p l e , he uses the h y p o t h e t i c a l ' B i l l : '  significance " . . .  they p a t t e r n e d together to c o m p r i s e the ' B i l l i a n ' q u a l i t y o f B i l l . s h o u l d e x p l o r e both h o r i z o n t a l a n d v e r t i c a l d i m e n s i o n s " (p. 410).  to  "Do the  i f so, how arc Ideally  research  -33B o g d e n (1974) echoes s i m i l a r c o n c e r n s about o v e r e m p h a s i s on the results of horizontal  methods o f research i n his defense o f the use o f a u t o b i o g r a p h y  as a  research tool: That  is, the a u t o b i o g r a p h y  another  view  point  which  e x a m i n e the p o s s i b i l i t y  adds  to  provides  that  they  theory  construction  professionals  are not d o i n g  with what  and  diagnoses  an opportunity they  profess  to  to be  d o i n g or that they are m i s r e p r e s e n t i n g those w h o m they c l a i m to be t e l l i n g us a b o u t .  T h i s r e a l i t y c o n f r o n t a t i o n c a n n o t help but be p r o d u c t i v e , (p. 4)  B o g d e n (1974) has raised t w o issues w h i c h issue q u e s t i o n s obtained  the a p p l i c a b i l i t y  to the i n d i v i d u a l  by " h o r i z o n t a l " methods o f study.  'theory construction.'  Survey  u n d e r l i e this s t u d y . of general  psychological  T h e second issue  Y i n (1984), i n his book Case Study Research  research  relies  on ' s t a t i s t i c a l '  The first laws  raised is that  of  states that:  generalization,  whereas  case  studies (as w i t h e x p e r i m e n t s ) rely on ' a n a l y t i c a l ' g e n e r a l i z a t i o n . In a n a l y t i c a l g e n e r a l i z a t i o n , the i n v e s t i g a t o r is s t r i v i n g to g e n e r a l i z e a p a r t i c u l a r set o f results to some b r o a d e r t h e o r y ,  (p. 39)  The  research  choice  o f the case s t u d y  as the p r e f e r r e d  i n v e s t i g a t i o n was based on the t w o above m e n t i o n e d issues. l i t e r a t u r e r e v e a l e d , there is c u r r e n t l y  design  for  this  A s the r e v i e w o f the  l i t t l e e m p i r i c a l d a t a a n d even less t h e o r y i n  the area o f post o p e r a t i v e t r a n s s e x u a l a d j u s t m e n t .  In a d d i t i o n to t h i s , the e x i s t i n g  research d e m o n s t r a t e s w h a t c o u l d be i n t e r p r e t e d as a n o v e r e m p h a s i s o n h o r i z o n t a l m e t h o d s o f s t u d y i n the area. operative focus  adjustment  is needed.  is a n a p p r o p r i a t e  F o r these reasons, more research f o c u s i n g on post T h e case s t u d y  and productive  method  method, with with  which  its ' m o r p h o g e n i c ' to c o n d u c t  this  - 34 research. From the results of this preliminary work, we can begin the process of theory construction which will have practical significance to clinicians working with this population.  The Case Subject The case subject is currently 39 years old. She works part time as a hair stylist and has lived for the past year with her common-law husband and his three year old son. When not working, much of her time is taken up with parenting the child and managing the household. The subject was born in a rural community in Saskatchewan. She was the younger of two sons (her brother is 4 years older). She was born with a bilateral cleft palate and bilateral cleft lip, which were repaired at the age of 8 months and then operated on again at the age of 12. The case subject described being cross-gender identified from her earliest memories. She reported that as a child, she always felt more comfortable playing the games of little girls rather than those of boys. It was during this period (prior to puberty) that she taught herself to sew. She began cross-dressing at an early age and continued to do so (though in secret) into her teenage years. As a teenager she was ridiculed by her peers, and also by her grade 9 teacher for her feminine behavior. At this time she resolved to leave high school and attend trade school in Toronto.  Though her parents were  initially resistant, they eventually supported this decision. During  this same period, the subject saw  Christine Jorgenson, reassignment  was  a television  a post operative male transsexual.  possible, she  approached  her  family  interview with  Realizing  that sex-  physician about  the  procedure. He recommended that she contact the Johns Hopkins Clinic where sex-  - 35 r e a s s i g n m e n t was c a r r i e d out.  Logistical and f i n a n c i a l considerations  eventually  p r e c l u d e d e n t r y i n t o the Johns H o p k i n s p r o g r a m . Approximately  three  years  later,  having  completed  school  and  s u c c e s s f u l l y l a u n c h e d her c a r e e r , the subject a p p r o a c h e d the p l a s t i c surgeon  who  h a d o r i g i n a l l y o p e r a t e d on her c l e f t palate a n d c l e f t l i p . C l a r k e Institute of Psychiatry  in Toronto.  trade  H e r e f e r r e d her to the  A p p o i n t m e n t s at the C l a r k e  Institute  were s e c u r e d i n the f a l l of 1971. B y t h i s t i m e the subject h a d d i s c l o s e d her desire f o r s e x - r e a s s i g n m e n t to her f a m i l y . d u r i n g this period.  She also h a d b e g u n c r o s s - l i v i n g  exclusively  T w o years later she was s u r g i c a l l y r e a s s i g n e d .  I m m e d i a t e l y a f t e r s u r g e r y the subject m o v e d to V a n c o u v e r w h e r e she began working  in  a large  salon.  Since  then  she  has l i v e d  in  Vancouver,  with  the  e x c e p t i o n of a three m o n t h p e r i o d (in the f i r s t year) i n w h i c h she m o v e d to R c g i n a a n d l i v e d w i t h her m o t h e r . In V a n c o u v e r salons.  Between  depression.  T h i s was a f t e r the b r e a k - u p of a r e l a t i o n s h i p .  her career has progressed. 1979 a n d  1982, h o w e v e r ,  She has both m a n a g e d a n d o w n e d she  suffered  several  T h e r e was also one s u i c i d e a t t e m p t d u r i n g this t i m e .  d e p r e s s i o n have not r e c u r r e d i n the last f i v e years.  periods  of  T h e i n s t a n c e s of  T h e basis o f the d e p r e s s i o n is  s o m e w h a t s p e c u l a t i v e at this t i m e , but appears at least p a r t i a l l y r e l a t e d to  work  pressures c o m b i n e d w i t h r e l a t i o n s h i p d i f f i c u l t i e s . T h e subject enjoys  warm  approval and  reports b e i n g stable a n d h a p p y  relations  with  acceptance of  supportive friendships. the post o p e r a t i v e role.  a l l members o f her.  her  i n her present s i t u a t i o n . immediate family  She m a i n t a i n s a n e t w o r k  of  who  She  express  meaningful  and  It appears that the subject has s u c c e s s f u l l y i n t e g r a t e d i n t o  - 36 T h e Case Study Investigator A c o m m o n f a c t o r i n a l l case studies is that the q u a l i t y o f the study  ulti-  m a t e l y rests on the e x p e r t i s e of the case s t u d y i n v e s t i g a t o r i n c o l l e c t i n g the d a t a :  This  is because the  data collection  procedures  are  not  routinized.  In  l a b o r a t o r y e x p e r i m e n t s or i n s u r v e y s , f o r i n s t a n c e , the d a t a c o l l e c t i o n phase o f a r e s e a r c h project c a n be l a r g e l y , i f not w h o l l y , c o n d u c t e d by a research assistant. The  assistant's goal  "• m i n i m u m  of  is to c a r r y  discretionary  routinized—and boring. (Yin  out the d a t a c o l l e c t i o n a c t i v i t i e s w i t h  behavior,  and  in  this  sense  the  activity  a is  T h e r e is no such p a r a l l e l i n c o n d u c t i n g case studies  1984; p. 56).  Y i n goes on to suggest a list of s k i l l s r e q u i r e d by the case s t u d y  investigator:  A person s h o u l d be able to ask good q u e s t i o n s — a n d to i n t e r p r e t the answers. A person s h o u l d be a good " l i s t e n e r " a n d not be t r a p p e d by his or her  own  i d e o l o g i e s or p r e c o n c e p t i o n s . A  person  should  be  adaptive  and  flexible,  so  that  newly  encountered  s i t u a t i o n s c a n be seen as o p p o r t u n i t i e s , not threats. A person must have a f i r m grasp of the issues b e i n g s t u d i e d , w h e t h e r this is a t h e o r e t i c a l or p o l i c y o r i e n t a t i o n , even i n an e x p l o r a t o r y  mode.  grasp  be  reduces  the  relevant  events  and  information  to  Such a  sought  to  manageable proportions. A  person  should  be  unbiased  by  preconceived  notions,  including  those  derived f r o m theory. T h u s , a person s h o u l d be s e n s i t i v e a n d r e s p o n s i v e to c o n t r a d i c t o r y (p. 56-57).  evidence,  - 37 The training  in  case s t u d y  investigator  counselling  f o r this  psychology.  As  project  a result  has r e c e i v e d of  this  graduate  training,  level  he has an  a c c e p t a b l e l e v e l o f c o m p e t e n c y at the s k i l l s o f l i s t e n i n g a n d q u e s t i o n i n g w h i c h Y i n (1984) h i g h l i g h t s as i m p o r t a n t .  In a d d i t i o n , he has s t u d i e d e x t e n s i v e l y i n the area  of t r a n s s e x u a l i s m a n d gender d y s p h o r i c b e h a v i o r a n d has been a b l e to d e m o n s t r a t e his k n o w l e d g e  o f the area w i t h  colleagues, supervisors  and practitioners  in the  field. The Serai-Structured Interview The  semi-structured  unstructured and structured  interview  attempted  to  draw  f o r m s o f the research i n t e r v i e w .  s t r i c t p r o t o c o l as i n the s t r u c t u r e d i n t e r v i e w , the i n t e r v i e w e r 'guide.'  from  both  R a t h e r than  the using  used a more general  T h e g u i d e c o n t a i n e d a series o f questions w h i c h served as a g e n e r a l p l a n  f o r the i n t e r v i e w e r (as opposed to a r i g i d list o f questions w h i c h were to be read verbatim). In c o m m o n w i t h u n s t r u c t u r e d i n t e r v i e w s , s k i l l s such as r e f l e c t i o n o f content a n d e m o t i o n , p r o b i n g , a n d open a n d closed q u e s t i o n s were used by the i n t e r v i e w e r in the i n t e r v i e w  process.  In a d d i t i o n , the i n t e r v i e w e r  was p r e p a r e d to (and d i d )  generate n e w q u e s t i o n s w h i c h resulted f r o m the i n f o r m a t i o n put f o r t h by the case subject d u r i n g the course o f the i n t e r v i e w s . The validity  use o f a v a r i e t y  o f the results.  o f sources o f d a t a c o l l e c t i o n s e r v e d to i n c r e a s e the  By interviewing  not o n l y  the case subject  but also her  f a m i l y a n d selected f r i e n d s , the i n t e r v i e w e r was accessing i n f o r m a t i o n w h i c h may have  been  forgotten  or  repressed  by  the subject.  Cauncl  and  Kahn  (1968)  i d e n t i f i e d three reasons f o r d a t a b e i n g i n a c c e s s i b l e t h r o u g h the i n t e r v i e w process:  - 38 1. the material is forgotten, 2. the material is repressed 3. the respondent lacks the cognitive structure to respond to the question posed (i.e. does not code the experience with the frame of reference from which the interviewer presents the question) (p. 532). The third area of data inaccessibility was approached in this investigation through eliciting of a 'story' followed by non-directive probing and reflection, aimed at discovering the effects of events within the stories related. Data Collection In this study, data were collected primarily through the interview method (see Table 3.1).  Interviews were conducted with the case subject, with members of  her family, with three of her friends, and conjunction with  with her common-law husband.  the interview data, standardized  In  psychological measures (the  Minnesota Multiphasic Personality Inventory, the Family Assessment Measure and  the  Social Support Questionnaire) were administered to assess the case subject's current psychosocial functioning. The study began by obtaining "human subject approval" (a process which included, the subject's consent in writing, to participate in the study).  Data  collection began with an initial interview with the case subject (see appendices C and  D  for interview guides).  This interview focused  on  basic demographic  information. In conjunction with demographic-type information (e.g. age, place of birth, schools attended etc.) a general life story was elicited from the individual. The purpose of this initial interview was to provide a framework and basis for the following interviews. Following  this, the  case  investigator visited  the  Clarke  Institute  of  Psychiatry (Toronto, Ontario) where the case subject had originally been assessed and  later surgically reassigned.  An  attempt was  made to interview the Chief  -39Psychiatrist who operatively.  had dealt personally  Unfortunately  with  the case subject  this was not p o s s i b l e ; h o w e v e r ,  both  pre-  the case  and  post  investigator  m e t - w i t h a n d i n t e r v i e w e d the c o o r d i n a t o r o f the G e n d e r I d e n t i t y P r o g r a m m e .  The  i n f o r m a t i o n r e s u l t i n g f r o m this m e e t i n g was u s e f u l i n o b t a i n i n g an u n d e r s t a n d i n g o f g e n e r a l c l i n i c a l trends i n w o r k i n g w i t h gender d y s p h o r i c  individuals.  It also  suggested issues to be e x p l o r e d i n later i n t e r v i e w s w i t h the case subject. W i t h the w r i t t e n consent of the case subject, T h e C l a r k e I n s t i t u t e t w o MMPI  p r o f i l e s (one  a d m i n i s t e r e d two  a d m i n i s t e r e d t w o years post o p e r a t i v e l y C l a r k e Institute case subject.  of P s y c h i a t r y  years  pre-operativcly  [1975]) a n d a b r i e f  released  [1971] a n d  one  case s u m m a r y .  The  was not p r e p a r e d to release the e n t i r e f i l e on the  T h e MMPI p r o f i l e s , c o m b i n e d w i t h the c u r r e n t p r o f i l e , a l l o w e d f o r a  comparison of  scores o v e r  a period  of  approximately  sixteen  years.  The  case  s u m m a r y suggested areas to be e x p l o r e d i n the i n t e r v i e w s w i t h the case subject. T h e second i n t e r v i e w decision  to seek t r e a t m e n t  w i t h the case subject f o c u s e d on the time f r o m the to the  t i m e of  surgery.  Information  p e r c e p t i o n s o f the assessment a n d t r e a t m e n t process was s o l i c i t e d .  regarding  her  In a d d i t i o n , her  m e m o r i e s r e g a r d i n g her r e a c t i o n s a n d the r e a c t i o n s of s i g n i f i c a n t persons in  her  l i f e was r e q u e s t e d . T h e t h i r d i n t e r v i e w w i t h the subject c e n t e r e d on p e r c e p t i o n s o f f a m i l y l i f e . Though including  i n f o r m a t i o n f r o m earliest recollections f o r w a r d , special  focus  was p l a c e d on how the f a m i l y h e l p e d a n d / o r h i n d e r e d —or i f they had an e f f e c t on a d j u s t m e n t to the new gender role. The  following  interviews  were  with  the  mother a n d b r o t h e r .  Questions  were f o c u s e d i n the areas of: f a m i l y r e l a t i o n s h i p s , s o c i a l r e l a t i o n s h i p s , w o r k s c h o o l f u n c t i o n i n g , f r o m the past, up to the present.  Both the mother a n d  b r o t h e r (and at later t i m e , the f a t h e r ) were i n t e r v i e w e d i n d i v i d u a l l y .  They  and the were  e n c o u r a g e d to g i v e e x p r e s s i o n to t h e i r o w n e x p e r i e n c e of b e i n g a witness to this  - 40 process as w e l l as t h e i r o b s e r v a t i o n s of its e f f e c t on the subject a n d the  people  a r o u n d her. T h e f o u r t h i n t e r v i e w w i t h the case subject f o c u s e d on ' r o m a n t i c ' l i f e .  Data  i n t h i s area were e l i c i t e d f o r both p r e - o p e r a t i v e a n d post o p e r a t i v e t i m e p e r i o d s . In a d d i t i o n , q u e s t i o n s f o c u s e d on b o t h h e t e r o s e x u a l a n d h o m o s e x u a l  experiences.  C o n s i s t e n t w i t h the r e s e a r c h f i n d i n g s i n the l i t e r a t u r e , the m a j o r i t y of e x p e r i e n c e s h a d o c c u r r e d post o p e r a t i v e l y .  romantic  T h i s t o p i c was g i v e n s p e c i a l a t t e n t i o n  ( a p p r o x i m a t e l y three a n d o n e - h a l f hours of i n t e r v i e w time) because p r i o r research suggested that r o m a n c e is a n area o f o n g o i n g d i f f i c u l t y individuals  (Hastings,  collection  as  possible.  experience  in  this area  1978) a n d  hence  it  As  other  interviews,  in  was f o c u s e d  was  f o r m a n y post  thought,  upon ( t h r o u g h  merited  the  as  much  individual's  the e l i c i t i n g of  operative data  subjective 'stories')  in  c o n j u n c t i o n w i t h c o n c r e t e events. T h e f i f t h i n t e r v i e w w i t h the subject f o c u s e d on p e r c e p t i o n s of f r i e n d s a n d peer  group.  This  included  reactions  to  disclosure,  duration  and  number  of  f r i e n d s h i p s , f e e l i n g s o f b e l o n g i n g versus i s o l a t i o n , changes i n the p e r c e p t i o n s  of  f r i e n d s o v e r t i m e , such as a c c e p t a n c e , r e j e c t i o n , etc.. I n t e r v i e w s w i t h three f r i e n d s o f l o n g s t a n d i n g a n d the case subject's  now  c o m m o n - l a w h u s b a n d ( c o - h a b i t a t i o n began d u r i n g the d a t a c o l l e c t i o n p e r i o d ) done  throughout  the  interviews  served  providing  new  interview  to c o r r o b o r a t e  information  i n d i v i d u a l s were asked f o r  to  period,  as  times  information be  noted  from  and  t h e i r p e r c e p t i o n s of  could the  be  case subject  explored. how  arranged.  In  the subject  were These  as w e l l  addition, in q u e s t i o n  as  these has  a d j u s t e d to the new role (e.g. s o c i a l l y , s e x u a l l y , i n r e l a t i o n to f a m i l y etc.). T h e s i x t h i n t e r v i e w w i t h the case subject the present. on  issues  of  f o c u s e d on the t i m e f r o m S R S to  T h o u g h s u m m a r i z i n g some i n f o r m a t i o n a l r e a d y o b t a i n e d , it role  adaptation  and  satisfaction  post  operatively.  The  focused seventh  - 41 i n t e r v i e w w a s used as a g e n e r a l s u m m a r y a n d d i s c u s s i o n o f the i m p a c t of this process (the d a t a c o l l e c t i o n ) on the case subject. F I G U R E 3.1 SCHEDULE OF DATA COLLECTION Source  Type of Data  Time Focus  Target Information  1. Case Subject (interview #1)  Interview data  past-present  -factual data -general life story -medical history -employment history -educational history  2. Visit to Clarke Institute of Psychiatry  Case records interview data (specific to subject and general background) past M M P I Profile  past  -demographic information, -clinical information -background information regarding transsexualism  3. Case subject (interview #2)  Interview data  past  -events from time of seeking treatment to surgery -reaction of family, friends and professional community -emotional state during this time -helping/hindering factors  4. Interview with Mother  Interview data  past-present  -reaction to disclosure -reaction of other members of family -reactions to cross-dressing -current acceptance/ rejection of gender reassignment -assessment of gender reassignment -helping/hindering factors in post operative adjustment  5. Interview with Brother  Interview data  past-present  -reaction to disclosure -reaction of other family members -reaction to cross dressing -current acceptance/rejection of gender reassignment -assessment of gender reassignment success/failure -helping/hindering factors in post operative adaptation  6. Case Subject (interview #3)  Interview data  past-present  -family life from childhood to adult family relations -role of family members in facilitating/ hindering adjustment -effect of SRS on relationships with family members  7. M M P I . S S Q and F A M (case subject)  Test data  present  -psychological functioning -social support measurement -family functioning  8. F A M (family members)  Test data  present  -family functioning  9. Case subject (interview # 4 )  Interview data  past-present  -romantic life -sexual relationships/experience -sexual satisfaction pre and post operatively -effect of transsexualism on romantic relationships  - 42 F I G U R E 3.1  S C H E D U L E O F D A T A C O L L E C T I O N (continued)  Source  Type of Data  Time Focus  Target Information  10. Interview with Father  Interview data  past-present  -helping/hindering factors -reaction to disclosure -reaction of other family members -reaction to subject's cross-dressing -current acceptance rejection of gender reassignment -assessment of success/failure of gender re-assignment  11. Case Subject (interview #5)  Interview data  past-present  -role of friendships -reaction of friends pre-and post operatively to disclosure of transsexualism -perceived degree of acceptance/rejection by friends -perceived sense of belonging versus i s o l a t i o n  12. Peer group  Interview data  past-present  -perception of adjustment to female role -perceived hindering/facilitating factors -acceptance/rejection of subject's transsexualism -assessment of subject's integration/ i s o l a t i o n in terms of social network  13. Case Subject (interview #6  Interview data  past-present  -assessment of surgical success -issues regarding assimilation into community as a woman  14. Case subject (interview #7)  Interview data  past-present  -summary of interview process -concluding remarks  What e m e r g e d  from  process o f t h i s person's l i f e .  the i n t e r v i e w s  was a series o f s u b j e c t i v e  accounts  of the  F r o m each i n t e r v i e w e e , a ' s t o r y ' was e l i c i t e d , f o c u s i n g on  e n v i r o n m e n t a l events a n d the case subject's r e a c t i o n to a n d i m p a c t on that e n v i r o n m e n t . Statements o f accounts. corroborate explored.  b e h a v i o r , o f f e e l i n g , a n d o f t h o u g h t were p r o b e d  for throughout  these  I n t e r v i e w d a t a , c o m i n g f r o m other t h a n the subject h e r s e l f served not o n l y 10 her statements  but  also  to generate  further  questions  a n d arenas  to be  - 43 Data Analysis Once  c o m p l e t e , the i n t e r v i e w  were  then  which  d a t a were  classified into Conger's  reduced  three  c r i t e r i o n f o r an i n c i d e n t to be c o n s i d e r e d as  levels  to a series of of  analysis. The  ' s i g n i f i c a n t ' was that the  o f this i n c i d e n t led to a n o b s e r v a b l e change or result.  incidents  occurrence  In e f f e c t , this r e q u i r e d  a l l i n c i d e n t s had to have r e s u l t e d i n a b e h a v i o r a l o u t c o m e (or at least to an o u t c o m e  which  had  a behavioral  component  to  primary  it).  Though  that  have had  cognitive  and  a f f e c t i v e e f f e c t s o f i n c i d e n t s were n o t e d , a c o n s c i o u s d e c i s i o n was made to restrict the ' i n c i d e n t s ' to h a v i n g a m i n i m u m to a v o i d  the ' h y p o t h e s i z i n g '  by  behavioral requirement.  the  interviewee,  (which  T h i s was done so as  Flanagan  [1954]  warns  against in c o n d u c t i n g a " C r i t i c a l Incident" study). T h e c l a s s i f i c a t i o n l e v e l , l a b e l e d " C o m m u n i t y " was the most d i s p a r a t e of the three l e v e l s , in terms of the m o t i v a t i n g sources of i n c i d e n t s . greatest n u m b e r of i n c i d e n t s .  It also c o n t a i n e d the  T o a d d c l a r i t y to this l e v e l , it was f u r t h e r  divided  i n t o s u b - c a t e g o r i e s r e f l e c t i n g the c o m m u n i t y systems (as o u t l i n e d by C o n g e r , 1981) i n v o l v e d w i t h the i n c i d e n t s (sec T a b l e 3.1). T A B L E 3.1 AN E X A M P L E OF THE  COMMUNITY  CLASSIFICATION  COMMUNITY Incident  Result  - m e d i c a l system - e d u c a t i o n a l system -friends The priori  n a t u r e of  the s u b - c a t e g o r i e s came out of  system (i.e. i n c i d e n t s  entitled  "Educational",  involving  incidents  c a t e g o r y " V o c a t i o n a l " , etc.).  the data i t s e l f  teachers were  involving  work  grouped experiences  rather into a  than any  a  sub-category  formed  the  sub-  - 44 T h e use of the s t a n d a r d i z e d i n s t r u m e n t s , each r e f l e c t i n g one of the levels of d a t a a n a l y s i s (i.e. i n d i v i d u a l , f a m i l y or c o m m u n i t y ) y i e l d e d i n f o r m a t i o n about the subject c u r r e n t l y  functions.  These results served to c o m p l e m e n t the  d a t a a n d p r o v i d e d an o p p o r t u n i t y  how  interview  to e x a m i n e the c o n v e r g e n c e a n d d i v e r g e n c e  of  i n f o r m a t i o n g e n e r a t e d f r o m the d i f f e r e n t sources. T h e p r e - a n d post S R S , Minnesota demonstrated  what  personality  Multiphasic  changes  have  Personality  taken  Inventory  place o v e r  time  profiles  (individual  level of analysis). From interviews,  the  historical and  the s t u d y  retrospective  a t t e m p t e d to show  d a t a , case r e c o r d s ,  the m a n n e r  p r i o r to a n d at the t i m e o f S R S , was f u n c t i o n i n g . current  in w h i c h  test scores the case  and  subject,  T h e d a t a c o l l e c t i o n , f o c u s i n g on  i n f o r m a t i o n , o b t a i n e d f r o m test scores a n d i n t e r v i e w s , d e m o n s t r a t e d  the subject f u n c t i o n s  how  today.  T h e a n a l y s i s o f the c r i t i c a l i n c i d e n t s a n d t h e i r results, o b t a i n e d by the use of  the " C r i t i c a l I n c i d e n t T e c h n i q u e "  'what' factors  have  been s i g n i f i c a n t .  a t t e m p t e d to a n s w e r From  responses  the i n i t i a l q u e s t i o n  within  the i n t e r v i e w s ,  of wc  a t t e m p t e d to a n s w e r ' w h y ' these f a c t o r s were seen as s i g n i f i c a n t by the i n d i v i d u a l s interviewed.  In a d d i t i o n , a c l a s s i f i c a t i o n a n a l y s i s of the ' c r i t i c a l i n c i d e n t s '  u n d e r t a k e n i n w h i c h the case subject o r d e r e d varying  from  'most  significant'  undertaken independently two  independent  rankings  to  'least  the i n c i d e n t s on a six  significant'.  by the case i n v e s t i g a t o r . was  then  calculated  The  The  point  same  correlation  so as to a s c e r t a i n  of the i n c i d e n t s .  scale  process  was  between  the  the  agreement between i n v e s t i g a t o r a n d subject on the q u e s t i o n o f r e l a t i v e  was  level  of  importance  - 45 The Critical Incident Technique Woolsey  (1985)  argues  that  a  practitioners in counselling psychology.  schism  exists  between  researchers  and  She suggests that this is at least i n part the  result o f the disuse o f research m e t h o d o l o g i e s w h i c h w o u l d h a v e r e l e v a n c e to, a n d use the s k i l l s o f the p r a c t i t i o n e r s (as w e l l as o f the researchers).  She goes on to  state:  T h u s , it seems i m p e r a t i v e to e x p l o r e new m e t h o d o l o g i e s i n r e s e a r c h , not o n l y to  better  address  the  research  question,  but  to  resolve  the  valuc-  i n c o n g r u e n c e b e t w e e n c o u n s e l l i n g theories a n d research p a r a d i g m s , so that c o u n s e l l o r s w i l l be e n a b l e d to f u l l y  develop  their  research p o t e n t i a l . . . .  H e n c e , it is i m p o r t a n t that i n n o v a t i v e methods be v a l u e - c o n g r u e n t as w e l l as practice effective.  Counsellor  training  participant  observation,  intra-personal  and  in  the vivid  skills  of  interviewing,  qualitative description  inter-personal  patterns  are a l l  empathic and  listening,  the a n a l y s i s  relevant  to  of  qualitative,  n a t u r a l i s t i c , p h e n o m e n o l o g i c a l a n d e c o l o g i c a l research strategies, (p. 2 - 3)  Woolsey (1985) presents the c r i t i c a l i n c i d e n t t e c h n i q u e as an e x a m p l e of a m e t h o d o f r e s e a r c h w e l l s u i t e d to be used by c o u n s e l l o r s . of acceptable v a l i d i t y  It meets the r e q u i r e m e n t s  and reliability while remaining congruent  with  humanistic  values.  In a d d i t i o n , the s k i l l s r e q u i r e d to execute the t e c h n i q u e c o m p l e m e n t  training  and  experience  of  most c o u n s e l l o r s .  e x p l o r a t o r y research (Woolsey,  It  is a t e c h n i q u e  appropriate  the o v e r a l l  a i m of  the a c t i v i t y  under  study  (in  this  study:  case,  o v e r a l l a i m was to s t u d y the process of a d a p t a t i o n to the gender reassigned (2) f o r m u l a t i n g  plans  and  to  1985).  F l a n a g a n (1954) i d e n t i f i e d f i v e steps i n c o n c l u d i n g a c r i t i c a l i n c i d e n t (1) d e t e r m i n i n g  the  specifications  for  collecting  information  about  the role); the  -46activity  studied  (in  this s t u d y  f a m i l y , friends and  the i n d i v i d u a l  herself,  were  g i v e n i n s t r u c t i o n s to r e p o r t on b e h a v i o r s , thoughts a n d f e e l i n g s w h i c h h a v e had an o b s e r v a b l e e f f e c t on the case subject's process of post o p e r a t i v e role a d a p t a t i o n ) ; (3) c o l l e c t i o n o f  the  information  by  the  process o f  interview  a n d case  record  a n a l y s i s ; (4) a n a l y s i s o f the d a t a ; (5) i n t e r p r e t a t i o n a n d r e p o r t i n g of the d a t a . A n d e r s s o n a n d N i l s s o n (1964) i n t h e i r s t u d y o f r e l i a b i l i t y a n d v a l i d i t y  of  the t e c h n i q u e , c o n c l u d e d that it a d e q u a t e l y assessed the c o n t e n t d o m a i n a n d that other  m e t h o d s of  addition  they  assessment w h e n  found  that  applied, did  different  interviewers  n u m b e r a n d d i s t r i b u t i o n of the c r i t i c a l i n c i d e n t s .  not  add  only  new  information.  marginally  affected  In the  T h e y c o n c l u d e d that the m e t h o d  a l l o w e d f o r the c o l l e c t i o n o f d a t a w h i c h was both r e l i a b l e a n d v a l i d .  The C r i t i c a l I n c i d e n t S c a l e F o l l o w i n g F l a n a g a n ' s (1954) g u i d e l i n e s  for  conducting a critical  incident  s t u d y , i n t e r v i e w s were c a r r i e d out w i t h the case subject, selected m e m b e r s o f her f a m i l y , and s p e c i f i c friends of long standing. the c r i t i c a l i n c i d e n t s were r e v e a l e d .  It was d u r i n g these i n t e r v i e w s  that  A l l i n c i d e n t s d e s c r i b e d by o t h e r t h a n the case  subject were discussed w i t h her d u r i n g later i n t e r v i e w s .  It was a r e q u i r e m e n t , f o r  the i n c i d e n t to be c o n s i d e r e d c r i t i c a l , that she agree w i t h the d e s c r i p t i o n of  the  f a c t s o f the i n c i d e n t a n d of its result. A scale was d e v e l o p e d so as to a l l o w  f o r a rater(s), i n t h i s case the case  subject a n d the case i n v e s t i g a t o r , to d i f f e r e n t i a t e levels of s i g n i f i c a n c e  between  the  "normal  30 i n c i d e n t s .  distribution"  of  The  six-level  incidents.  To  scale was  designed  a c c o m p l i s h this each  so as to level  force  was  only  a  allowed a  s p e c i f i e d n u m b e r of i n c i d e n t s ( L e v e l O n e , one i n c i d e n t ; L e v e l T w o , f o u r i n c i d e n t s ; Level Three,  10 i n c i d e n t s ; L e v e l  L e v e l S i x , one i n c i d e n t ) .  Four,  10 i n c i d e n t s ; L e v e l  Five,  four  incidents;  - 47 F o r a n y i n c i d e n t to be c o n s i d e r e d ' c r i t i c a l ' i t h a d to h a v e h a d some type of o b s e r v a b l e result.  T h i s d e f i n e d the m i n i m a l r e q u i r e m e n t o f L e v e l O n e : that the  i n c i d e n t r e s u l t e d i n a s i n g l e consequence or b e h a v i o r .  T h e second l e v e l s p e c i f i e d a  series or g r o u p of c o n s e q u e n c e s / b e h a v i o r s as a result o f the i n c i d e n t .  Level Three  a d d e d the d i m e n s i o n o f a t t i t u d i n a l change to the b a s i c b e h a v i o r a l  requirements  a n d L e v e l F o u r e x t e n d e d the b e h a v i o r a l a n d a t t i t u d i n a l c o m p o n e n t s o v e r a greater p e r i o d o f t i m e (greater t h a n three months).  incorporated  observable  consequences i n others as a result of the changes f o r the case subject.  L e v e l Six  marked  the  single  most  significant  Level Five  incident  as d e f i n e d  by  its  long  term  or  p e r m a n e n t r a m i f i c a t i o n s on b e h a v i o r a n d a t t i t u d e c h a n g e f o r the case subject and others i n v o l v e d in her l i f e .  Standardized  Instruments  Three Multiphasic Support  standardized  Personality  Inventory,  Questionnaire.  primarily  instruments  were  Family  the  T h e Minnesota  used  in  this  Assessment  Multiphasic  study:  Measure  Personality  Inventory  of  the same i n s t r u m e n t .  This  resulted  Family  The  Assessment  Measure  the  attempts to i n t e g r a t e  Social  was chosen profile  i n b e i n g able to  c h a n g e i n p s y c h o l o g i c a l a d j u s t m e n t (as m e a s u r e d by the MMPI) years.  and  because it a l l o w e d the researcher to c o m p a r e the c u r r e n t  past p r o f i l e s  Minnesota  the  with  measure  o v e r some s i x t e e n both s y s t e m i c  n o n s y s t e m i c theories of p s y c h o l o g i c a l a d j u s t m e n t w i t h i n the f a m i l y .  and  It also focuses  on the process of f a m i l y i n t e r a c t i o n r a t h e r t h a n on f a m i l y s t r u c t u r e ( w h i c h was of d o u b t f u l a p p r o p r i a t e n e s s i n v i e w of the ages of the c h i l d r e n , a n d of t h e i r separate domiciles).  The  Social  Support  social  support.  Family  Assessment  Questionnaire A  number  Measure  was chosen f o r  these reasons.  The  tested the subject's p e r c e p t i o n o f the a d e q u a c y o f her of  instruments  in  this  topic  area  were  reviewed,  - 48 h o w e v e r , the Social  Support  Questionnaire  was chosen here f o r the types o f  support  it measures, as w e l l as f o r its r e p o r t e d v a l i d i t y a n d r e l i a b i l i t y .  Minnesota Multiphasic Personality Inventory The  Minnesota  Multiphasic  Personality  Inventory  and  McKinley,  1967) f i r s t a p p e a r e d i n 1940 a n d since that t i m e has become the most  extensively  researched  paper-and-pencil  index  of  T h e MMPI  ( H o p k i n s a n d S t a n l e y , 1981).  (Hathaway  psychological  adjustment  in  existence  consists of ten " c l i n i c a l scales" a n d three  " v a l i d i t y scales." T h e ten c l i n i c a l scales are as f o l l o w s :  1. Hs:  Hypochondriasis  6. P a : P a r a n o i a  2. D:  Depression  7. Pt:  Psychasthenia  8. Sc:  Schizophrenia  4. P d : P s y c h o p a t h i c d e v i a t e  9. M a :  Hypomania  5. M f :  0. S i : S o c i a l I n t r o v e r s i o n  3. H y :  Hysteria  Masculinity-femininity  T h e three v a l i d i t y scales (L)  L i e Score:  consist of:  C a l c u l a t e d f r o m a g r o u p of items w h i c h w o u l d a p p e a r to put the  e x a m i n e e i n a f a v o u r a b l e l i g h t but i n r e a l i t y a r c u n l i k e l y to be a n s w e r e d in the scored d i r e c t i o n i f the e x a m i n e e is a n s w e r i n g (F)  Validity  Score:  C a l c u l a t e d f r o m a set of  truthfully.  items w h i c h  though  describing  u n d e s i r a b l e b e h a v i o r arc not f r e q u e n t l y a n s w e r e d i n the scored d i r e c t i o n by any  standardization  abnormality errors,  or  As  psychopathology.  carelessness  ( f a k i n g bad).  group.  in  a A  set  they  high  F  adhere score  the e x a m i n e e ' s responses  or  to  may  no  pattern  indicate  deliberate  of  scoring  malingering  -49(K)  C o r r e c t i o n Score: K  score  may  favourable  T h e K score is a measure o f test t a k i n g a t t i t u d e .  indicate  light.  A  defensiveness low  K  score  and/or may  an  attempt  be i n d i c a t i v e  to of  A  high  appear  in a  excessive  self  responds  with  c r i t i c i s m or m a l i n g e r i n g ( A n a s t a s i , 1982). The "true"  MMPI  " f a l s e " or  diagnosis,  consists o f 550 statements to w h i c h the s u b j e c t "cannot  reports  of  say".  test  Used  scores on  r e s e a r c h on t r a n s s e x u a l i s m .  primarily this  for  instrument  the  process  are  not  of  differential  uncommon  in  the  T h o u g h there is c o n s i d e r a b l e e v i d e n c e to suggest that  e l e v a t i o n on the c l i n i c a l scales is i n d i c a t i v e of p s y c h o l o g i c a l d i s t u r b a n c e ( A n a s t a s i , 1982), research i n the area of t r a n s s e x u a l i s m has not d e m o n s t r a t e d a consistent or t y p i c a l t r a n s s e x u a l p r o f i l e ( W c a t h e r h e a d , et a l . , 1978).  T h e i n s t r u m e n t has also not  p r o v e d to be r e l i a b l e in terms of its a b i l i t y to p r e d i c t post o p e r a t i v e a d j u s t m e n t (L. C l e m m e n s o n , p e r s o n a l c o m m u n i c a t i o n , F e b r u a r y , 1986). The  MMPI  was  used in this project  as a measure of  a d j u s t m e n t a n d o f change i n a d j u s t m e n t over t i m e . operative)  1975 (post o p e r a t i v e )  both  psychological  Test scores f r o m 1971 (pre-  a n d 1987 (post o p e r a t i v e )  were i n t e r p r e t e d .  This  a l l o w e d f o r d i r e c t c o m p a r i s o n of f u n c t i o n i n g , as m e a s u r e d by t h i s i n s t r u m e n t . T h e i n d i v i d u a l f o r m o f the MMPI  was used on a l l three tests.  T h e test was  a d m i n i s t e r e d a n d scored i n 1971 a n d 1975 by the s t a f f of the C l a r k e I n s t i t u t e of Psychiatry  a n d by  the case s t u d y  investigator  for  the  1987 a d m i n i s t r a t i o n .  An  o u t s i d e p s y c h o l o g i s t , ( D r . T o m T o m b a u g h , C a r l e t o n U n i v e r s i t y ) e x p e r t i n the area of MMPI  i n t e r p r e t a t i o n , was e n l i s t e d f o r the task of i n t e r p r e t i n g a l l three o f the  p r o f i l e s f o r this project. review. MMPI:  H i s d i s c u s s i o n of the p r o f i l e s was a u d i o taped f o r  later  T h e p r i m a r y r e f e r e n c e f o r i n t e r p r e t a t i o n , used by D r . T o m b a u g h , was: The Clinical  Assessment  and Automated  Interpretation.  (1974).  - 50 The Family Assessment Measure T h e Family Assessment Measure ( S k i n n e r , S t e i n h a u e r & S a n t a - B a r b a r a , 1984) d e v e l o p e d at the A d d i c t i o n R e s e a r c h F o u n d a t i o n ( T o r o n t o , O n t a r i o ) is a s e l f - r e p o r t i n s t r u m e n t w h i c h attempts to measure elements o f f a m i l y s t r e n g t h a n d weakness. The  basic  dimensions  assessed  by  the  FAM  are: task  accomplishment,  role  p e r f o r m a n c e , c o m m u n i c a t i o n , a f f e c t i v e e x p r e s s i o n , i n v o l v e m e n t , c o n t r o l , values a n d norms.  T h e assessment o f these d i m e n s i o n s is a c c o m p l i s h e d t h r o u g h three separate  scales: the G e n e r a l S c a l e , D y a d i c R e l a t i o n s h i p Scale a n d S e l f R a t i n g Scale.  Each  scale a l l o w s f o r a d i f f e r e n t perspective o f f a m i l y f u n c t i o n i n g ( S k i n n e r , S t e i n h a u e r & S a n t a - B a r b a r a , 1983). the d y n a m i c interplay  T h e FAM is based on a "Process M o d e l " w h i c h e m p h a s i z e s  i n t e r a c t i o n s o f major aspects o f f a m i l y  between  interpersonal.  the  individual  T h e focus  a n d the  is one o f process  group: rather  functioning the  than  as w e l l as the  intrapsychic structure.  a n d the  (Steinhauer,  S a n t a - B a r b a r a & S k i n n e r , 1984). T h e s t a n d a r d i z i n g groups (475 f a m i l i e s i n the T o r o n t o area) a r e d e s c r i b e d i n Skinner  et a l . , 1983.  Demographic  information,  including  age, sex, length  of  c o h a b i t a t i o n , n u m b e r o f c h i l d r e n , e d u c a t i o n l e v e l , i n c o m e , etc., d e m o n s t r a t e s that a heterogeneous  p o p u l a t i o n served as the n o r m i n g group.  R e l i a b i l i t y estimates f o r  the o v e r a l l scales f o r a d u l t s range f r o m .89 to .93 a n d f o r c h i l d r e n , f r o m .86 to .94. Reliability children.  r a t i n g s f o r each o f the subscales are also g i v e n  T h e range f o r a d u l t s is f r o m a l o w o f .39 (Self R a t i n g : C o n t r o l ) to a h i g h  o f .87 ( G e n e r a l children  (Skinner, robust.  Scale: Social Desirability).  is .27 (Self  Relationships). subscale  f o r both a d u l t s a n d  Rating: Role  T h e range f o r subscale r e l i a b i l i t y f o r  Performance)  to .77 ( C o m m u n i c a t i o n :  Dyadic  R e l i a b i l i t y is a f f e c t e d by the n u m b e r o f i t e m s , a n d the decrease i n  reliability,  to a degree,  et a l . 1984).  is to be expected  The primary  on these  briefer  subscales  scale r e l i a b i l i t i e s c a n be c o n s i d e r e d  A multivariate comparison of problem and nonproblem  quite  f a m i l i e s is also  - 51 reported.  results s u p p o r t e d the FAM  The  G e n e r a l Scale's a b i l i t y to d i s c r i m i n a t e  b e t w e e n ' p r o b l e m ' a n d ' n o n p r o b l e m ' f a m i l i e s ( S k i n n e r , et a l . 1984). T h e d e v e l o p m e n t o f the c o n s t r u c t s (i.e. of the Process M o d e l ) u p o n the FAM is based are d e t a i l e d i n S t e i n h a u e r et a l . (1984). that r e s e a r c h i n t o e x t e r n a l v a l i d a t i o n of  A t present it is r e p o r t e d  the c o n s t r u c t s is o n g o i n g .  f u r t h e r r e s e a r c h e x a m i n i n g its c o n c u r r e n t v a l i d i t y ( c o r r e l a t i o n instruments)  is  n o t e d , as  is  research  into  its  which  clinical  and  In  addition  w i t h other predictive  family validity  ( S k i n n e r et a l . 1983). T h e FAM  is a s e l f - a d m i n i s t e r e d i n s t r u m e n t .  D i r e c t i o n s f o r c o m p l e t i o n of  the scales are on the f r o n t cover of the c o r r e s p o n d i n g q u e s t i o n b o o k l e t . case s u b j e c t ,  the  investigator  guidelines for completion. the q u e s t i o n n a i r e s .  reviewed  the  purpose  of  the  FAM  and  W i t h the general  H e r e m a i n e d present w h i l e the case subject c o m p l e t e d  T h e other f a m i l y members (who do not l i v e i n the same c i t i e s  as each o t h e r or as the case i n v e s t i g a t o r ) were c o n t a c t e d by t e l e p h o n e ( p e r m i s s i o n h a d been g r a n t e d  for  t h i s at a p r i o r  meeting).  During  this conversation,  the  i n v e s t i g a t o r r e v i e w e d the purpose of the test and g u i d e l i n e s f o r c o m p l e t i o n .  The  b o o k l e t s a n d q u e s t i o n / a n s w e r sheets, w i t h an a t t a c h e d letter r e i t e r a t i n g i n s t r u c t i o n s a n d r a t i o n a l e , were then m a i l e d to each of the f a m i l y m e m b e r s , w h o c o m p l e t e d the tests a n d m a i l e d t h e m back to the case i n v e s t i g a t o r . E a c h scale consists of answers w i t h examinee  "strongly  transform  agree," "agree," "disagree," or " s t r o n g l y  m a r k s the a n s w e r  a t t a c h e d scorer's sheets. the  raw  e i t h e r 42 or 50 statements to w h i c h  sheet, the  m a r k s are  transferred  test-taker  disagree."  As  (carbon  copy)  F r o m this the scorer c a n c a l c u l a t e r a w scores, a n d  scores  to  standard  scores  (tables  provided).  p r o v i d e d f o r g r a p h i c d i s p l a y a n d c o m p a r i s o n , as arc g u i d e l i n e s f o r of the scores.  the  Profiles  the to  then arc  interpretation  - 52 T h e FAM  was chosen f o r this project  not o n l y f o r its r e p o r t e d  v a l i d i t y a n d ease o f a d m i n i s t r a t i o n , but also f o r structure  and  its  psychopathology.  attempt  to  integrate  reliability,  its f o c u s on process r a t h e r  systems  theory  with  than  individual  T h e e m p h a s i s it places on the " i n t e r f a c e b e t w e e n the i n d i v i d u a l  subsystems a n d the f a m i l y system" ( S t e i n h a u e r , et al.,1984, p. 78) was t h o u g h t to be e x t r e m e l y a p p r o p r i a t e to this case s t u d y . T h e case subject was a s k e d to c o m p l e t e a l l of the q u e s t i o n n a i r e s f r o m point  of  view  of  how  separate d o m i c i l e s ) .  the  family  currently  functions  (keeping  T h e subject c o m p l e t e d three D y a d i c  r e l a t i n g to her m o t h e r , her f a t h e r a n d her broth er).  in  mind  the their  R e l a t i o n s h i p Scales (i.e.  T h e other  family  members  w e r e e a c h a s k e d to c o m p l e t e a G e n e r a l Scale a n d a D y a d i c S c a l e ( c o n s i d e r i n g  their  relationship  three  different collection)  with  views of  the case subject). (note:  the  the f a m i l y  This  allowed  for  the c o m p a r i s o n  f a t h e r d e c l i n e d to p a r t i c i p a t e  of  i n this s e c t i o n of  f u n c t i o n i n g , as w e l l as d i f f e r e n t  views  on  the  data  dyadic  r e l a t i o n s h i p s o f the case subject w i t h other f a m i l y members.  Social Support Questionnaire The  Social  Support  Questionnaire  (Sarason,  Lcvinc,  Basham and  Sarason,  1983) was used as a measure of a d e q u a c y of s o c i a l support. In d i s c u s s i n g issues in the m e a s u r e m e n t o f s o c i a l s u p p o r t , Sarason et a l . state that:  R e g a r d l e s s o f h o w it is c o n c e p t u a l i z e d , s o c i a l s u p p o r t  w o u l d seem to have  t w o b a s i c elements: (a) the p e r c e p t i o n that there is a s u f f i c i e n t n u m b e r  of  a v a i l a b l e others to w h o m one c a n t u r n i n times of need a n d (b) a degree of s a t i s f a c t i o n w i t h the a v a i l a b l e support (p. 128-129).  - 53 In p r e s e n t i n g his v i e w of the c o n c e p t u a l issues i n v o l v e d i n the area of s o c i a l s u p p o r t m e a s u r e m e n t , T a r d y (1985) suggests that there are f i v e b a s i c d i m e n s i o n s i n defining  the  construct.  He  represents  these  dimensions  D i s p o s i t i o n , (c) D e s c r i p t i o n / E v a l u a t i o n , (d) C o n t e n t , (e) Direction received.  he sees as b e i n g the d i r e c t i o n  of  as: (a)  Direction,  (b)  Network.  the s u p p o r t :  either  given  or  T h e issue is not w h i c h d i r e c t i o n is s t u d i e d but r a t h e r that the d i r e c t i o n  is o v e r t l y d e l i n e a t e d . Disposition,  like  Direction  is  seen  as  comprising  two  complimentary  components: a v a i l a b i l i t y (quantity and/or quality) and u t i l i z a t i o n . D e s c r i p t i o n / E v a l u a t i o n refers a g a i n to two r e l a t e d f a c e t s o f s o c i a l s u p p o r t . D e s c r i p t i o n r e f e r s o n l y to the existence of s u p p o r t s , w h i l e e v a l u a t i o n r e f e r s to the i n d i v i d u a l ' s l e v e l o f s a t i s f a c t i o n w i t h the support a v a i l a b l e .  R e s e a r c h is r e p o r t e d  w h i c h l o o k s at these facets i n d i v i d u a l l y a n d together. Content distinguished  of  s o c i a l support  among  four  is c o n c e p t u a l i z e d  types  of  support  by  citing  content:  House  emotional,  (1981),  who  instrumental,  i n f o r m a t i o n a l and appraisal. The  term  Network  describes  the existence  of a support  network  without  i m p l y i n g a d i r e c t i o n f o r the s u p p o r t ( T a r d y , 1985, p. 188-190). Having  reviewed  a variety  Support Questionnaire {SSQ) Inspection  o f the SSQ  of  the  was chosen f o r  instruments  in  this s t u d y  for  Direction  question and  of not  the  area,  a number  the of  Social reasons.  reveals that it too meets T a r d y ' s b a s i c c r i t e r i a (1985)  c o v e r i n g the r a n g e o f b a s i c elements of s o c i a l s u p p o r t . the  this  support  being  discussed  f r o m the i n d i v i d u a l .  In  focuses o n a v a i l a b i l i t y r a t h e r t h a n on e n a c t m e n t . both o v e r t l y m e a s u r e d by the i n s t r u m e n t .  T h e SSQ c l e a r l y states that  is c o m i n g  terms o f  for  'to'  the  individual  D i s p o s i t i o n , the  in  instrument  Description and Evaluation  arc  C o n t e n t tends to r e f e r p r i m a r i l y ( t h o u g h  - 54 not  exclusively)  to  emotional  support  and  finally,  a series of  projects  investigating  a  Network  of  support  is  m e a s u r e d by the SSQ. In  reporting  Basham, found  and  that  Sarason, N  scores  1983) a study (number  of  of  the SSQ,  602 u n d e r g r a d u a t e  persons  available)  had  (Sarason,  Levine,  university  an  internal  students reliability  c o e f f i c i e n t (between items) o f .97 a n d the c o r r e l a t i o n of items w i t h the t o t a l score r a n g e d f r o m .51 to .79. T h e S scores ( s a t i s f a c t i o n ) h a d an a l p h a c o e f f i c i e n t o f .94 w h i l e the c o r r e l a t i o n of i n d i v i d u a l items w i t h the t o t a l score r a n g e d f r o m .48 to .72.  The  test-retcst  reliability  administered)  was .90 ( N  further  study  reported  studies  in  support  and  (for  scores) a n d  significant  this scries c o r r e l a t e the o c c u r r e n c e  of  c o r r e l a t i o n s (in f e m a l e subjects)  the  105 students  to  whom  .83 (S scores)  over a 4 - w e e k  negative correlations measure  negative  with  lack  l i f e events  the  test  was  re-  interval.  A  with depression. of  satisfaction  as w e l l  Other  in  social  significant  positive  between N scores a n d e x t r o v e r s i o n , a n d  negative  c o r r e l a t i o n s (in f e m a l e subjects also) between n e u r o t i c i s m scores a n d S scores. a u t h o r s note that on the latter two studies the results f o r  men were  The  in the same  d i r e c t i o n as f o r w o m e n but were not as strong. The  combination  of  construct  and  concurrent  validity,  r e l i a b i l i t y , o u t w e i g h the d i s a d v a n t a g e o f the i n s t r u m e n t not h a v i n g norming population.  and  internal  an  exten si v e  T h e a u t h o r s r e p o r t a range o f N scores f r o m 2.92 to 5.46 w i t h  a m e a n o f 4.25 a n d a range of S scores f r o m 5.12 to 5.57 w i t h a mean of 5.38. These  ranges  university  means  are  reported  on  the  sample  of  602  undergraduate  students.  Like reviewed  and  the  FAM,  the  SSQ  is  largely  self-administered.  The  the r a t i o n a l e a n d g u i d e l i n e s f o r c o m p l e t i n g the q u e s t i o n n a i r e  researcher with  case subject, a n d then r e m a i n e d present i n the r o o m w h i l e she c o m p l e t e d it.  the The  test consisted of 27 items to w h i c h the subject was r e q u i r e d to: (a) list the pcrson(s)  - 55 -  (by  i n i t i a l s a n d r e l a t i o n s h i p ) to w h o m she c o u l d t u r n f o r s u p p o r t  i n the  manner  d e s c r i b e d by the q u e s t i o n , (b) c i r c l e the s a t i s f a c t i o n l e v e l w i t h the o v e r a l l  support  a v a i l a b l e f o r each of the areas q u e s t i o n e d (i.e. on a scale o f " 1 - v e r y d i s s a t i s f i e d " to "6-very satisfied"). The  overall  N  a n d S scores  were  c a l c u l a t e d by  t a k i n g the s u m of  s e c t i o n ( N a n d S) a n d d i v i d i n g by the n u m b e r of items (27).  each  - 56 -  CHAPTER IV RESULTS Introduction  The use of the three standardized measures allowed for an assessment of the case subject's functioning in three different domains. The instruments were chosen in part for their approximate  correspondence  (individual, family and community).  to Conger's levels of assessment  In addition, as was noted in Chapter III, the  Minnesota Multiphasic Personality Inventory had been used on two prior occasions to assess the psychological functioning of the case subject.  The comparison of  these three MMPI profiles (two historic and one current) allowed for an assessment of change in scores over a sixteen year time period, from the first to the current profile (sec figure 4.1).  MMPI Profile  Interpretations  The 1971 profile showed significant elevations (defined as a T score of 70 or greater) on scales 7, 8 and 9. More moderate elevations (T score of greater than 60) were evident on scales 2, 3 and 4. This profile was interpreted as belonging to a person who was extremely careful, perhaps to the point of being obsessive (L scale = 0).  The scores showed evidence of worrying, self preoccupation and  schizoid tendencies (pattern of 7, 8, 9, elevations). obsessive-compulsive and schizoid tendencies, delusions or psychotic reactions.  Though the scores showed both  there was no evidence of actual  The depression scale (2) was elevated to suggest  some ongoing depression and an overall lack of pleasure in life.  Other qualities  suggested in the interpretation were: high energy (scale 9) and perhaps at times a sense of confusion about a world in which the subject somehow felt that he did not belong (scales 6 & 8). (pattern of scales 7, 8, & 9).  There was also some evidence of interpersonal panic  -57-  Flgure 4.1  7  M  MINNESOTA MULTIPHASIC PERSONALITY INVENTORY S.R Hathaway a n d I (  M> K i n l r v  PROFILE MINNESOTA MULTIPHASIC PERSONALITY INVENTORY Copyright • THE UNIVERSITY Of MINNES01A IW3. Renewed 1970 This Profile Form 1948.1916.1982 All rights reseived Distributed Etclusrvery by NATIONAL COMPUTER SYSTEMS INC Unde> License from The University of Mmne^a PrintHl •» *r '>*itm S i » « of A i r — " •)  Minnesota Multiphasic Personality Inventory" a"0 MMPI" art trademark* owned by The U".vr*vTv o' Minnesota  7 Pt+IK  TorTe  M  MALE  -  30-  SO-  8 Sc+IK  55 -  45-  30-  50-  40-  40-  frietmi of K K 5 .4 2  M  SO -  1  40-  X 15 12 29 IS 12 a 14 t l < 27 14 t l 5 1} 10 S  «  45 -  »  15 -  25 1) 10 5 24 12 10 5 23 12 9 5 22 t l 9 4 21 It t 4  20 10 19 10 ia 9 17 9 16 1  4d 120-  <0 -  IS -  »/>»  29 -  4 4 3 3  20-  JO 15 14 1] 12  It  40 -  30-  i 4 a i j 6  45 -  30 —  S 1 3 7 7 s  «  6 3 5 3 S 2 4 2  10 9 a 7 t  s s 4 4 3  4 4 3 3 2  2 2 2 1  i  3 2 2  2 2 1 1 0 ')  1 1 1 0 0 0  15  )-  -  2025 -  5 -  ?5 -  20 -  K -  t 15 -  i i  2 1 1 t 0 0  IS -  0 -  torTc  Raw Score.  0  8  10  7 23 23 21 45 13 25 _4_ 10 K to be added _5_ 12 25 35 Raw Score with K  25 24 10 2 35 26  30  -58-  F l g u r e 4.2  7  MINNESOTA MULTIPHASIC PERSONALITY INVENTORY  M  S R . Hathaway and J.C M c k i n l e y PROFILE ItMNCSOIA MULTIPHASIC PERSONALITY INVENTOR* Copyt<nt < THE UMVEftSITY OF MMNES01A 1943 Renewed 1970 The Prohtt form I9«S 1978. 1982 AHngWiitseivto OskOUttd EjCkiS<vely by NATIONAL COMPUTER SYSTEMS INC Unoei LcenseftomThe Umverany ot Minnesota Pim*e n the Unflec Su*» ot AmeicJ  TorTe  '  I  t  K  Minnesota Multiphasic Personality Inventory" anc MMPr are traOemarKs owned by The University ol Minnesota  1 MI+5K  7 Pl+IK  8 SC+1K  17011 110•rattens* K K i 4 3 X 79 76 77 76  IS ts 14 14 13  17 1? 11 11 10  6 6  • 5 5  S 5 73 17 > 5 77 11 9 4 M 11 B 4  •4  10 10 6 9 7 t 7 1 t  4 4 3 3  15 I 6 3 14 7 e 3 5 3 17 1 6 7 II t 4 2 13  65•  45-  50-  1»  60-  50-  . 100-  45-  4045-  » 90  »74 1317 1010  70 It 18 17 te  FEMALE  75 -  3550-  40-  35-  60 45-  40-  y  2« 25-  •  •  i i < 7 3 7 7 1 I 1 0 0  2 2 2 t l  7 I ? 1 1 1 1 0 0 0 0 0  3540-  353030 -  7  10 s 4 i 4 6 » 3 7 3 i 7  45 •  •15-  to-.  SO-  75-  30 —  75 -  65  553C -  60-  70  35-  Ti-  n-  50-  35 70-  80-'  5! -  ts -  40-  «S-  55-  40-  60-  /  35-  X70-  30-  70/  jo-  35-  45 >5 -  40-  5-  20-  15 15-  35 •' J 0 -  15-  45 -  10105 —  100 -  5 -  75-; n  10 -  10-  10-  -. 0 -  TorTc  Raw Score.  '  i  _L  >  «  H>-» 5« 1  0 1  Hy 3  P*+4« 4  HI 8  Pi 8  Pl+IK 7  Sc+IK 8  Ml-f 2« t  S> O  A.1 1 J _ JA2Q_L7_iLtl_^_5_21_lJb8 19 19 4 K to be added _1P 23" 25 24 25 Raw Score with K Jli  -59-  MINNESOTA MULTIPHASIC ' PERSONALITY INVENTORY S.R. H a t h a w a y a n d ).C  McKinlev  PROFILE  MINNESOTA MULTIPHASIC PBSONAUTY INVENTORY CopyitgM • THE UNIVERSITY OF MINNESOTA 190. Renewed 1970. This Promt Form t9*J.1978.1982. All fights reserved ftstrtbuted Exdusrvery by NATIONAL COMPUTER SYSTEMS. INC Under License from The University of Minnesota Printed m the United Slates of America  Raw Score  3  3  18  1  K to be added _2_ Raw Score with K  10  Minnesota Multiphase Personality Inventory" -ir.1 MMPI Irndemams flwned by The University ol Minnesota  15 21 _7_ 21  _4_ 23 21 19  - 60 Inspection  of  s i g n i f i c a n t changes.  the  1975 p r o f i l e  (two  years  after  surgery)  showed  several  T h e K scale h a d r i s e n f r o m a T=41 i n the 1971 p r o f i l e to a  T=61 i n 1975. T h i s level o f e l e v a t i o n on the K scale, i n c o n j u n c t i o n w i t h a low L score (T=52) r a i s e d some questions.  T h e p a t t e r n of a h i g h K a n d l o w L scores may  have  in  reflected  a l a c k of  validity  the p r o f i l e , or  it  may  have  signified  an  i n c r e a s e i n ego s t r e n g t h (i.e. the i n d i v i d u a l was not ' f a k i n g g o o d ' but r a t h e r  felt  good about  has  herself).  participated  in  This  pattern  psychotherapy.  profiles,  this  profile  strength  was  accepted).  also tends  After  review  was a c c e p t e d as v a l i d Other  changes  e l e v a t i o n of scale 2 (depression).  from  to o c c u r and (the  after  an  individual  comparison hypothesis  with of  1971 i n c l u d e d  the  other  increased  the  ego  decrease  in  It was i n t e r p r e t e d that post o p e r a t i v e l y , the case  subject was e x p r e s s i n g less a n a d o n i a a n d more pleasure i n l i f e .  E l e v a t i o n s on scale  4 (T=64) a n d scale 9 (T=71) were i n t e r p r e t e d as e v i d e n c e o f a h i g h - e n e r g y  person  w h o holds a c e r t a i n sense o f anger a n d w h o as a result has the p o t e n t i a l to 'act out' in some n e g a t i v e w a y . 1971 p r o f i l e .  T h i s h i g h energy a n d i n n e r anger was also e v i d e n t in the  It s h o u l d be noted that the n o n - c l i n i c a l scale 5 had by t h i s  time,  d r o p p e d to 31 (T=70) f r o m 45 (T=97). Taken  in  its  entirety,  the  1975 p r o f i l e  was  interpreted  p s y c h o l o g i c a l l y ' h e a l t h i e r ' person t h a n d i d the 1971 p r o f i l e .  as  reflecting a  T h e d r o p of scales 7  a n d 8 were e v a l u a t e d as s i g n i f y i n g a c c e p t a n c e , r a t h e r t h a n r e j e c t i o n o f s e l f , and the d r o p o f scale 2 d e m o n s t r a t e d that the subject was a t t a i n i n g more pleasure in life. The  1987 p r o f i l e s h o w e d o n l y scale 5 (a non c l i n i c a l scale) as b e i n g e l e v a t e d  b e y o n d one s t a n d a r d d e v i a t i o n (T=64).  S c o r i n g on the " F e m a l e " p r o f i l e (since both  75 a n d 87 are post o p e r a t i v e p r o f i l e s ) the e l e v a t e d M F score was i n t e r p r e t e d as s h o w i n g the case subject as more assertive a n d aggressive t h a n the mean of reference  population. This  was  thought,  however,  to  be q u i t e  appropriate  the and  - 61 c o n s i s t e n t w i t h the role e x p e c t a t i o n s of the w o r k i n g w o m a n i n our  present  day  society.  E v i d e n c e of d e p r e s s i o n as w e l l as o f obsessional t h i n k i n g was no longer  present.  A l l c l i n i c a l scales on this (1987) p r o f i l e f e l l w i t h i n the n o r m a l range.  Scale 9 ( h y p o m a n i a ) on this c u r r e n t p r o f i l e d r o p p e d to w i t h i n one s t a n d a r d d e v i a t i o n o f the m e a n . the  previous  based.  F r o m t h i s , it c a n be suggested that the ' e n e r g y ' e v i d e n t in  profiles  was  probably  anxiety  driven  rather  than  physiologically  T h e e v i d e n c e o f anger (scale 4) present i n the 1971 a n d 1975 p r o f i l e s was  n o t i c e a b l y decreased i n the 1987 p r o f i l e . The  current  individual.  profile  Overall,  was seen as b e l o n g i n g  these  three  profiles  to a p s y c h o l o g i c a l l y  indicated  an  individual  'healthy'  who,  over  s i x t e e n y e a r p e r i o d , h a d become less r i g i d a n d more f l e x i b l e , less s t e r e o t y p e d terms  of  sex  role  behavior,  significantly  more  relaxed,  less a n x i o u s  and  a in  more  a c c e p t i n g of h e r s e l f a n d c a p a b l e of d e r i v i n g more pleasure f r o m l i f e .  F a m i l y Assessment M e a s u r e A l l three f o r m s o f the Family to  the  case subject:  R e l a t i o n s h i p Scale.  The  General  The  case subject's  G e n e r a l scale a n d the D y a d i c with  Assessment  the case subject).  The  Scale, The  Measure  (FAM)  Individual  mother  and  Scale a n d  brother  R e l a t i o n s h i p Scale ( f o c u s i n g case subject's f a t h e r agreed  d e c l i n e d to c o m p l e t e the F A M q u e s t i o n n a i r e s .  were a d m i n i s t e r e d The  Dyadic  also c o m p l e t e d on t h e i r  the  relationship  to be i n t e r v i e w e d  but  T h i s s e c t i o n o f d a t a c o l l e c t i o n has  a l l o w e d f o r the c o m p a r i s o n of d i f f e r e n t p e r c e p t i o n s of f a m i l y f u n c t i o n i n g a n d of d y a d i c r e l a t i o n s h i p s between the subject a n d her m o t h e r , a n d the subject brother.  a n d her  T h o u g h i n f o r m a t i o n f r o m the f a t h e r w o u l d have been u s e f u l f o r a d d e d  c o m p a r i s o n , the r e l a t i o n s h i p w i t h v i e w of the case subject.  h i m is d e s c r i b e d , but o n l y  f r o m the p o i n t  of  -62I d e n t i c a l i n s t r u c t i o n s were g i v e n to each o f the i n d i v i d u a l s c o m p l e t i n g the questionnaires.  The  instructions  necessitated  members.  was  one  modification by  made  the separate  to  the  living  standard situations  FAM of  all  family  E a c h person was i n s t r u c t e d to a n s w e r the q u e s t i o n s to the best o f t h e i r  a b i l i t y , f r o m the p e r s p e c t i v e o f h o w the f a m i l y f u n c t i o n s c u r r e n t l y . ("Family  manual  d u t i e s are f a i r l y  Q u e s t i o n #2  shared") was used as an e x a m p l e o f a q u e s t i o n  m i g h t be c o n f u s i n g because o f t h e i r separate l i v i n g s i t u a t i o n s .  which  It was suggested to  each f a m i l y m e m b e r that the t e r m ' d u t i e s ' c o u l d s t i l l a p p l y , but not i n the same sense (e.g. h o u s e h o l d duties) that it w o u l d have w h e n they were a l l l i v i n g  together.  After  were  discussion  with  each o f the i n d i v i d u a l s ,  it a p p e a r e d  that  there  no  d i f f i c u l t i e s i n u n d e r s t a n d i n g a n d r e l a t i n g the q u e s t i o n s to t h e i r c u r r e n t s i t u a t i o n . Once  the q u e s t i o n n a i r e s  were  c o m p l e t e d , responses  were  scored a n d  then  t r a n s f o r m e d i n t o s t a n d a r d scores as per d i r e c t i o n s i n the i n t e r p r e t a t i o n g u i d e .  The  m e a n f o r s t a n d a r d scores is 50 a n d the s t a n d a r d d e v i a t i o n is 10. I n t e r p r e t a t i o n the  profiles  was c o m p l e t e d  by  the case  investigator.  For  the G e n e r a l ,  of  Dyadic  R e l a t i o n s h i p , a n d S e l f R a t i n g P r o f i l e s , see F i g u r e s 4.4, 4.5, 4.6, a n d 4.7.  Interpretation On  scales r a t i n g  Social Desirability  and Defcnsiveness,  a t t a i n e d s t a n d a r d scores o f 55 a n d 62 r e s p e c t i v e l y .  the case  subject  T h e D e f e n s i v e n e s s score, b e i n g  greater t h a n one s t a n d a r d d e v i a t i o n above the m e a n , s i g n i f i e d the p o s s i b i l i t y some degree o f d e f e n s i v e n e s s or ' f a k i n g g o o d ' i n the o v e r a l l was k e p t i n m i n d i n the i n t e r p r e t a t i o n o f the p r o f i l e .  profile.  of  T h i s score  B y c o m p a r i n g the scores of  the case subject w i t h those o f the mother a n d b r o t h e r , an assessment o f the risk o f the p r o f i l e b e i n g i n v a l i d was made.  In the o p i n i o n o f the case i n v e s t i g a t o r , the  p r o f i l e o f the case subject was a v a l i d o n e , based o n a c o m p a r i s o n o f her scores w i t h those o f the other f a m i l y members.  -63Figure  4.4  FAM GENERAL SCALE  - 64 T h e case subject's O v e r a l l R a t i n g f o r the f a m i l y ( c a l c u l a t e d by f i n d i n g the mean score f o r the seven c l i n i c a l subscales) was a s t a n d a r d score of 48, w e l l w i t h i n the n o r m a l range. the o n l y  W i t h the e x c e p t i o n of the a f o r e m e n t i o n e d D e f e n s i v e n e s s scale,  score to f a l l  out o f  the n o r m a l range  (i.e. greater  than  d e v i a t i o n f r o m the mean) was that of the A f f e c t i v e I n v o l v e m e n t . score  of  38 suggested  high  levels  of  empathic  involvement  members, mutual concern and a nurturing and supportive other.  one  standard  The  subject's  between  involvement  family  w i t h each  B o t h the m o t h e r ' s score (47) a n d brother's score (54) suggested s o m e w h a t less  p o s i t i v e v i e w s o f t h i s d i m e n s i o n , h o w e v e r both scores f e l l w i t h i n the n o r m a l range f o r n o n p r o b l e m a t i c f a m i l i e s i n the n o r m i n g g r o u p . The  subscales  measuring  greatest d i s p a r i t y of scores. the c o n t r o l  subscale.  This  Control,  and  Values  and  Norms,  showed  the  T h e case subject a t t a i n e d a s t a n d a r d score of 41 on would  suggest  that she v i e w s  the  manner  in  which  c o n t r o l a n d p o w e r is w i e l d e d w i t h i n the g r o u p as b e i n g a f a m i l y s t r e n g t h . FAM  The  i n t e r p r e t a t i o n g u i d e suggested that e x t r e m e l o w scores ( d e f i n e d as less t h a n  40) i n d i c a t e p a t t e r n s of p r e d i c t a b i l i t y demands,  and  that  control  and  yet f l e x i b i l i t y  attempts  at  i n the m e e t i n g o f c h a n g i n g  control  arc  largely  constructive,  educational and nurturing. The  subject's  score  on  this subscale  was  in  significant  contrast  m o t h e r ' s score, w h i c h at 6 5 , was greater t h a n 2 s t a n d a r d d e v i a t i o n s a w a y .  to  her  A score  of t h i s m a g n i t u d e w o u l d suggest that the mother v i e w s the issue o f c o n t r o l as b e i n g p r o b l e m a t i c w i t h i n the f a m i l y .  The  FAM  Administration  and  Interpretation  Guide  suggested that scores above 60 may s i g n i f y a n y of the f o l l o w i n g : "patterns of ongoing  i n f l u e n c e not a l l o w i n g the f a m i l y  family  life;  the f a i l u r e to p e r c e i v e  to master the r o u t i n e s  and adjust  to c h a n g i n g  of life  d e m a n d s ; a l a c k o f s p o n t a n e i t y or its o p p o s i t e , chaos, i n issues o f p o w e r a n d c o n t r o l ; a style w h i c h is too r i g i d or too l a i s s e z - f a i r e ; c o n t r o l a t t e m p t s w h i c h  - 65 are destructive or shaming and family patterns which are characterized by overt or covert power struggles" (p. 19). As a contrast subscale. scores.  to both of these extreme scores, the brother scored 55 on this  A number of possible explanations were evident for this disparity in The father and mother have been divorced for a number of years and  perhaps the mother's score related more to the past marital dyad (and hence memories of past marital conflict) than to the family as a whole.  Another  possibility was that control was an issue on which the three family members reacted  to uniquely; what was problematic for the mother  was an area of  satisfaction for the case subject, and of little concern for the brother. Considering the defensiveness score of the case subject, there was some suppression of negative aspects of this content area in her scores.  On the subscale Values and Norms the  mother again scored beyond the 'normal' range. Her score of 64 would suggest that she perceived this also, as being a problematic dimension for the family.  The case  subject and her brother, however, both scored near the mean, with scores of 47 and 51  respectively.  Inspection of this subscale  revealed  that  it shares  certain  characteristics with the Control subscale. Values and Norms includes concepts such as family rules, societal norms and rules, and the identification of the congruence or incongruence between the family's values and those of the society at large. Where the Values and Norms subscale identified rules, norms and values, the Control subscale is complimentary in that it looks at the enforcement of such. It is therefore  not surprising that problematic scores on one subscale  foreshadow  problematic scores in the other. Considering the sibling agreement on the Values and Norms subscale (in a nonproblematic direction) it could be argued that the hypothesis regarding the disparity of scores on the "control" subscale, being due at least in part to remnants of marital discord, was strengthened.  - 66 T h e case subject a n d her mother s h o w e d the same score on the subscale of R o l e p e r f o r m a n c e (56) w h i l e the b r o t h e r at a score o f 48 a p p e a r s to have t h i s as a n area o f s o m e w h a t greater s t r e n g t h .  perceived  T h o u g h there is some d i s p a r i t y  in  scores here, it was not c o n s i d e r e d s i g n i f i c a n t since a l l o f the scores f e l l w i t h i n the n o r m a l range a n d also f e l l w i t h i n one s t a n d a r d d e v i a t i o n of each oth er. three  clinical  subscales  (Task  Accomplishment,  Role  The  other  Performance  and  C o m m u n i c a t i o n ) a l l f e l l w i t h i n the n o r m a l range a n d the scores of the three f a m i l y members f e l l w i t h i n one s t a n d a r d d e v i a t i o n o f each other. T h e m e a n O v e r a l l R a t i n g s ( f o r a l l three test takers) f e l l w i t h i n the n o r m a l range.  In  spite  of  significant  differences  C o n t r o l a n d V a l u e s a n d N o r m s ) the O v e r a l l  on  specific  subscales  (Involvement,  Ratings fell relatively  close ( w i t h i n  one s t a n d a r d d e v i a t i o n ) to each other. It  should  be noted  that  the  norming  population  for  FAM  the  docs  not  i n c l u d e f a m i l i e s w i t h a d u l t c h i l d r e n no longer l i v i n g i n the same d o m i c i l e as the parents. "FAM  The  case i n v e s t i g a t o r  Research  Project"  that  was assured by this  instrument  the R e s e a r c h C o o r d i n a t o r has  been  found  to  be  of  the  valid  for  f a m i l i e s at this stage, h o w e v e r , the r e l a t i o n s h i p of this f a m i l y ' s scores to the scores of  problematic  and  nonproblematic  families  s h o u l d be i n t e r p r e t e d w i t h some c a u t i o n .  used  as  the  reference  population  -67Figure  4.5  FAM PROFILE  •So  f  if  o  So  /  /  «9  Hi  70  cf  5>  70  En crj O  ^•1  CO  g>  H30 Subject Mother  - 68 -  Interpretation In  rating  her r e l a t i o n s h i p  with  her m o t h e r ,  the case subject  scored  an  O v e r a l l R a t i n g o f 51.5. T h i s was the average o f the seven c l i n i c a l subscales ( a l l of w h i c h f e l l w i t h i n .5 s t a n d a r d d e v i a t i o n s o f the mean). p o s i t i v e d i r e c t i o n was on the subscale o f T a s k  T h e most e x t r e m e score i n a  A c c o m p l i s h m e n t (46).  T h e most  e x t r e m e scores i n a n e g a t i v e d i r e c t i o n were f o r the subscales o f C o m m u n i c a t i o n (55) a n d o f V a l u e s a n d N o r m s (55). I n s p e c t i o n o f the g r a p h i c r e p r e s e n t a t i o n of the p r o f i l e ( f i g u r e 4.3) shows that these scores f e l l w i t h i n the ' n o r m a l ' range.  T h i s was  i n c o n t r a s t , h o w e v e r , to the mother's r a t i n g o f this same r e l a t i o n s h i p . A t an O v e r a l l R a t i n g o f 4 0 , the case subject's mother a p p e a r e d to p e r c e i v e the r e l a t i o n s h i p as g e n e r a l l y b e i n g c h a r a c t e r i z e d by e x t r e m e a d a p t i v e n e s s . Inspection  o f the subscales i n the m o t h e r ' s p r o f i l e  revealed a number  scores s i g n i f i c a n t l y d i v e r g e n t f r o m the those o f the case subject.  of  O n a l l subscales  except T a s k A c c o m p l i s h m e n t , the mother scored the r e l a t i o n s h i p i n the d i r e c t i o n o f 'greater s t r e n g t h ' t h a n d i d the case subject.  T h i s was most e v i d e n t on the subscales  of: A f f e c t i v e E x p r e s s i o n (28), I n v o l v e m e n t (32), a n d C o n t r o l (40). of  this s t u d y  d i d not i n c l u d e an i n t e n s i v e  clinical  S i n c e the f o c u s  assessment o f  the mother's  p e r c e p t i o n o f her r e l a t i o n s h i p w i t h the case subject, this o u t s t a n d i n g result c o u l d not be c o n c l u s i v e l y e x p l a i n e d . one i n t e r v i e w mother  with  perceives  Based on the results o f t h i s q u e s t i o n n a i r e a n d on  the m o t h e r , it was the case i n v e s t i g a t o r  her r e l a t i o n s h i p  openness, e m p a t h y a n d c a r i n g .  with  her d a u g h t e r  i m p r e s s i o n that the  as b e i n g c h a r a c t e r i z e d  by  -69Figure  4.6  FAM PROFILE  Subject Brother  -70Interpretation The  case subject's  rating of  her  relationship  with  her  brother  showed a  s o m e w h a t greater range i n scores t h a n d i d his r a t i n g of his r e l a t i o n s h i p w i t h  her.  T h e O v e r a l l R a t i n g , f o r the case subject, was s h o w n at 54 w i t h a range of scores f r o m 49 ( R o l e P e r f o r m a n c e ) to 60 ( A f f e c t i v e  Expression and Values and  Norms).  T h e A f f e c t i v e E x p r e s s i o n score suggested that c o m m u n i c a t i o n b e t w e e n the t w o , in the case subject's o p i n i o n , has a n i n a p p r o p r i a t e e m o t i o n a l q u a l i t y to it r e l a t i v e to the s i t u a t i o n ( e i t h e r e x t r e m e l y l a c k i n g or l a d e n w i t h e m o t i o n a l i t y ) .  H e r score f o r  the V a l u e s a n d N o r m s subscale s i g n i f i e d that she sees her v a l u e s a n d those of her b r o t h e r as b e i n g s o m e w h a t opposed. With  the  exception  of  these  two  subscale  scores,  there  was  very  close  a g r e e m e n t b e t w e e n the s i b l i n g s on t h e i r r e l a t i o n s h i p (all other subscale scores were w i t h i n t w o p o i n t s of each other).  O n the subscales of A f f e c t i v e I n v o l v e m e n t a n d  V a l u e s a n d N o r m s the b r o t h e r scored 53 a n d 54 r e s p e c t i v e l y .  These latter  two  subscales r e p r e s e n t e d the greatest d i s p a r i t y i n scores w i t h the case subject, yet s t i l l fell  within  one  standard  deviation.  The  brother's  Overall  a p p r o x i m a t e l y one p o i n t less t h a n the case subject's r a t i n g .  Rating  was  52.25,  -71Figure  4.7  FAM PROFILE  Subject's Rating: Dyadic R e l a t i o n s h i p With Father  - 72 Interpretation  The case subject's rating of her relationship with her father suggested that on -some dimensions this was viewed as a somewhat more problematic relationship. The Overall Rating for the profile, at 55.85, was within the normal range.  The  range of scores was from 49 (Role Performance) to 63 (Control). A comparison of this profile and the case subject's dyadic profile with her brother showed some strong similarities, though this was a profile of more extreme scores.  The most  extreme score (negative) was on the subscale Control (which was also the point of greatest divergence  from the profile with the brother).  This score suggested  problems centering on issues such as: failure to perceive and adjust to change, inappropriate attempts at control, and ongoing power struggles. The next highest  score was in the area of Affective Expression  followed by a score of 58 on Affective Involvement.  (60)  The Affective Expression  score was identical to the score on the dyadic profile with the brother and suggested  problems in the area of affective  Involvement  communication.  score was within the high normal range.  The Affective  It suggested  possible  difficulty in the area of affective/emotional involvement (either too close or too detached).  -73Figure  4.8  FAM PROFILE  Self  Rating  - 74 Interpretation On 51.7:  the S e l f R a t i n g scale, the case subject a t t a i n e d a n O v e r a l l  S i x o f the seven scales f e l l between 47 a n d 54.  was f o r  the  suggested subject's  subscale, Values  some d i s t u r b a n c e  and  Norms.  centered  The  values a n d those of the f a m i l y g e n e r a l l y .  of  T h e one o u t s t a n d i n g score  score  on p e r c e i v e d  Rating  of  60 on  dissonance  this  between  subscale, the  case  T h i s score m a y also have been  s h o w i n g c o n f l i c t i n the area o f f a m i l y r u l e s , s p e c i f i c a l l y b e t w e e n o v e r t a n d c o v e r t rules.  These scores w i l l be discussed f u r t h e r  collection in Chapter  in the c o n t e x t o f  the o v e r a l l d a t a  V.  Social Support Questionnaire T h e results f o r the Social Support Questionnaire (SSQ)  i n d i c a t e d that the case  subject's p e r c e i v e d l e v e l o f s o c i a l s u p p o r t , across the s i t u a t i o n s p r e s e n t e d , r a n g e d i n n u m b e r ( N score) f r o m 4 to 8 people (mean = 5.7).  T h e a u t h o r s r e p o r t e d , that in  t h e i r r e s e a r c h w i t h college students the N scores r a n g e d f r o m 2.92 to 5.46 w i t h an o v e r a l l mean of 4.25. T h e case subject's S score ( s a t i s f a c t i o n l e v e l w i t h the support a v a i l a b l e ) was 6 ( v e r y s a t i s f i e d , the highest possible score) f o r a l l o f the s i t u a t i o n s rated.  The  range of S scores that the a u t h o r s  report  was 5.12 to 5.57 w i t h  an  o v e r a l l mean o f 5.38. T h e case subject's results on this i n s t r u m e n t , suggested that she has a greater l e v e l o f s o c i a l s u p p o r t a n d is more s a t i s f i e d w i t h the q u a l i t y of s u p p o r t a v a i l a b l e , t h a n the  reference  group  supplied  by  the  instrument's authors.  However,  c o m p a r i s o n m a y not have been a v a l i d one, s i n c e the r e f e r e n c e g r o u p s a m p l e o f college students. social support  between  this  used is a  T h e r e m a y be s i g n i f i c a n t d i f f e r e n c e s i n the area o f  t h i s r e f e r e n c e s a m p l e a n d other  more i n c o m m o n w i t h the case subject.  populations  which  have  - 75 I n s p e c t i o n of the i n d i v i d u a l test items r e v e a l e d that the case subject  had  l i s t e d a m i n i m u m of f o u r sets of i n i t i a l s f o r each o f the s i t u a t i o n s posed. r e l a t i o n s h i p s l i s t e d a p p e a r e d to represent both f a m i l y a n d f r i e n d s .  The  Though  c o m b i n a t i o n s o f people c h a n g e d across s i t u a t i o n s , the a n s w e r s d e m o n s t r a t e d there were a n u m b e r o f people w h o r e c u r r e d across a v a r i e t y o f s i t u a t i o n s .  the that  These  people i n c l u d e d : f a m i l y o f o r i g i n members (i.e. m o t h e r , f a t h e r a n d b r o t h e r ) f r i e n d s and common-law husband.  T h e o v e r a l l p i c t u r e appears to be one of a c i r c l e  of  close f r i e n d s a n d f a m i l y , w h o the case subject b e l i e v e s c a n be r e l i e d u p o n to be s u p p o r t i v e across a v a r i e t y o f l i f e s i t u a t i o n s . The  consistent  scoring of  s a t i s f a c t i o n l e v e l at ' 6 ' , r a i s e d the q u e s t i o n  w h e t h e r or not this was a v a l i d r e f l e c t i o n of the a c t u a l l e v e l o f s a t i s f a c t i o n or t h i s was some f o r m o f answered, however,  'response set.'  T h i s question  could  not  be  of if  definitively  the i n t e r v i e w d a t a suggested that there was a l o n g h i s t o r y  of  close a n d s u p p o r t i v e f r i e n d s h i p s .  The C r i t i c a l Incidents In  his  description  of  the  Critical  Incident  Technique,  d e f i n e d an ' i n c i d e n t ' as " . . . a n y o b s e r v a b l e h u m a n a c t i v i t y  Flanagan  (1954)  that is s u f f i c i e n t l y  c o m p l e t e i n i t s e l f to p e r m i t i n f e r e n c e s a n d p r e d i c t i o n s about the person p e r f o r m i n g the act" (p. 327). T h e i n c i d e n t was seen as " c r i t i c a l " i f it " . . . o c c u r s in a s i t u a t i o n w h e r e the purpose or i n t e n t o f the act seems f a i r l y c l e a r to the o b s e r v e r a n d where its  consequences  e f f e c t s " (p. 327).  are  sufficiently  defined  to  leave  little  doubt  concerning  In t h i s s t u d y , the d e f i n i t i o n s were m o d i f i e d s l i g h t l y .  its  A 'critical  i n c i d e n t ' was d e f i n e d as a n event w h i c h o c c u r r e d w i t h i n the a w a r e n e s s of the case subject  and  resulted  i n an o b s e r v a b l e  consequence to, or  subject, w h i c h lasted over some p e r i o d of time.  behavior  by  the case  T h o u g h it was a c k n o w l e d g e d that  a result or c o n s e q u e n c e m a y be of an a f f e c t i v e or c o g n i t i v e n a t u r e a n d hence not  - 76 be o b s e r v a b l e , f o r the purposes of this s t u d y , the event was r e q u i r e d to have some o b s e r v a b l e c o m p o n e n t ( t h o u g h other n o n o b s e r v a b l e were r e p o r t e d  as w e l l ) .  The  c l a s s i f i c a t i o n of  components, if  acknowledged,  the c r i t i c a l i n c i d e n t s is s h o w n  T a b l e 4.1.  T A B L E 4.1 ECO-SYSTEMIC CLASSIFICATION OF CRITICAL INCIDENTS Incident  Perceived Result  Individual # 1 - S u i c i d e a t t e m p t age 15 #2-First crossdressing in public #3-Change of surname # 4 - S u i c i d e a t t e m p t age 31  - T e a c h e r becomes less a b u s i v e - N e v e r dresses as a m a l e a g a i n - L e s s c o n c e r n w i t h h i d i n g the past, greater honesty -Change in relationships  Family # 5 - M o t h e r d i s c o v e r s that subject has not a t t e n d e d A i r Cadets # 6 - d i s c o v e r y of letters re. S R S #7-telling father and brother a b o u t e f f o r t s to a t t a i n S R S # 8 - f i r s t post S R S C h r i s t m a s C a r d  - N o f u r t h e r pressure at home r e g a r d i n g a c t i v i t i e s -open discussions about S R S -open c o m m u n i c a t i o n w i t h father and brother -feelings of acceptance  Community (Educational) # 9 - R i d i c u l e d by G r a d e 9 teacher #10-Attending Trade School (Medical) #1 1 - P s y c h i a t r i s t makes transsexual diagnosis # 1 2 - F i r s t response f r o m J o h n Hopkins # 1 3 - P l a s t i c surgeon supports S R S # 1 4 - b e i n g c a l m e d by surgeon  -less interest i n s c h o o l -becomes q u a l i f i e d h a i r s t y l i s t  -Subject writes J . H o p k i n s Clinic - S u b j e c t c o n t i n u e s to w r i t e - r e f e r r a l to C l a r k e Institute -relief and confidence post s u r g e r y  in  - 77 T A B L E 4.1 (continued) ECO-SYSTEMIC CLASSIFICATION OF CRITICAL INCIDENTS (Vocational) # 1 5 - S u b j e c t begins to c h a r g e f o r hairstyling #16-buys first salon in O x b o w #17-organizes community hair a n d f a s h i o n show. #18-wins provincial hair competition # 1 9 - f i r e d f r o m job i n T o r o n t o # 2 0 - E x - b o s s asks Subject to r e t u r n to R e g i n a #21-buys salon in R e g i n a # 2 2 - R c g i n a salon burns down (social/friends) # 2 3 - G o i n g to A i r C a d e t s # 2 4 - f a m i l y f r i e n d speaks to son a n d his f r i e n d s 'about H e n r y ' #25-moves to V a n c o u v e r to l i v e with boyfriend # 2 6 - j o i n s West E n d P l a y e r s #27-moving in with common-law ( c o m m u n i t y at large) #28-sees C h r i s t i n e J o r g c n s o n on T.V. # 2 9 - m a n on p l a n e c o m m e n t s on attractiveness # 3 0 - g o i n g to bar w i t h c o u s i n i n Toronto  -extra money allows for e x p a n s i o n o f the business -is successful f i n a n c i a l l y -receives positive public attention - m o v e s to R e g i n a -boss o f f e r s a j o b i n R e g i n a - r e t u r n s to R e g i n a - t r a p p e d by debts, u n a b l e to sell - m o v e s to V a n c o u v e r  - f e e l s h u m i l i a t e d does not r e t u r n - t h e boys cease r i d i c u l i n g subject - r e t u r n s to R e g i n a -change in social l i f e -change in l i f e circumstances  -seeks i n f o r m a t i o n a b o u t transsexualism -stops c r y i n g -increased confidence and continued socializing  Situational Influences A s a result o f the i n t e r v i e w range  of  influences  and  process, it was d i s c o v e r e d  situations  which  could  not  be  that there were a  clearly  classified  as  i n c i d e n t s (due to t h e i r l a c k of o b v i o u s , b e g i n n i n g a n d end p o i n t s ) yet a p p e a r e d to be s i g n i f i c a n t to the p s y c h o l o g i c a l a n d s o c i a l a d j u s t m e n t of the case subject. are presented  in Table  C r i t i c a l Incidents.  4.2, e m p l o y i n g  the same c l a s s i f i c a t i o n system as f o r  They the  - 78 TABLE  4.2  ECO-SYSTEMIC CLASSIFICATION OF SITUATIONAL INFLUENCES Influence  Perceived Result  Individual # l - u n a t h l e t i c as a c h i l d # 2 - l e a r n i n g to sew a n d cut hair  # 3 - r e a l i z i n g that it made her f e e l better to be honest w i t h people she c a r e d about # 4 - a l w a y s f e l t r e l a x e d as a woman # 5 - o n e year spent crossdressing in Toronto # 6 - o n g o i n g d e p r e s s i o n 19801984  -spent a lot of t i m e a l o n e , s e w i n g - d u r i n g teens these p r o v i d e the subject w i t h a s e r v i c e to o f f e r peers a n d as an a d u l t these become v i a b l e v o c a t i o n a l skills -Immediate f a m i l y a l l knew about subject's d e s i r e f o r S R S by 1971 ( p r i o r to c r o s s - l i v i n g i n T o r o n t o ) - d i d n ' t f e e l that she h a d to w o r k at ' p a s s i n g ' - c o n f i d e n t w h e n dressed as a w o m a n - v o c a t i o n a l i n s t a b i l i t y a n d excessive use o f a l c o h o l a n d d r u g s  Family # 7 - n o r e j e c t i n g responses f r o m f a m i l y m e m b e r s (re. S R S )  -always felt supported and taken seriously  Community # 8 - b e i n g i n t r o d u c e d to the G a y c o m m u n i t y in R e g i n a #9-ongoing interviews with p s y c h i a t r i s t at the C l a r k e Institute #10-befriending a woman subject saw as self destructive #11-occasionally feel 'read' d u e to v o i c e  -developing empathic friendships -positive therapeutic alliance w h i c h increased d e t e r m i n a t i o n a n d f a i t h i n a b i l i t y to succeed - m o t i v a t i o n to c h a n g e b e h a v i o r patterns o f 1980-1984 -has a t t e m p t e d to m o d i f y unsuccessfully  but  - 79 T A B L E 4.3 A COMPARISON OF T H E CASE SUBJECT'S AND CASE INVESTIGATOR'S SIGNIFICANCE RATINGS OF T H E CRITICAL INCIDENTS Number of Incidents 10 9 8 7 6 5 4 3 2 1 09*  1  Column * Column **  23**  23* 01* 15* 05* 2  14** 12** 15** 05**  28* 20* 12* 10* 06* 23* 22* 21* 19* 16* 3  29** 18** 17** 13** 01** 23** 22** 21** 19** 16**  29* 18* 17* 13* 30* 26* 24* 11* 04* 03* 4  28** 20** 10** 09** 30** 26** 24** j j ** 04** 03**  14* 27* 08* 07*  06**  27** 08** 07**  5 6 Levels of Importance  Case Subject's ratings Case Investigator's ratings  The Product Moment correlation between the Case Subject's significance ratings and the Case Investigator's significance ratings: r = .55 Table 4.3 displays the results of the case subject's and case investigator's ratings of the critical incidents, using the scale developed for that purpose (and described in Chapter III). Pearson's Product Moment Correlation was calculated between the two sets of ratings (r = .55). As can be seen by inspection of Table 4.3, there was substantial disagreement between the case investigator and case subject in rating the relative importance of the Critical Incidents. discussed further in Chapter V.  This result will be  - 80 -  CHAPTER V SUMMARY AND DISCUSSION  T h i s project was based o n the p r e m i s e that the post o p e r a t i v e a d j u s t m e n t of t r a n s s e x u a l i n d i v i d u a l s c a n be p o s i t i v e l y a f f e c t e d by c o u n s e l l i n g , p r i o r to, a n d post surgical sex-reassignment.  T h e p r i m a r y purpose o f t h i s s t u d y was to e x a m i n e the  development a n d ongoing adjustment of a single i n d i v i d u a l .  B y f o c u s i n g on the  c u r r e n t p s y c h o l o g i c a l a n d s o c i a l a d j u s t m e n t o f this i n d i v i d u a l , a n d t h e n a t t e m p t i n g to d i s c o v e r  what  factors  h a d been s i g n i f i c a n t  to t h i s  person's  a d j u s t m e n t , the  r e s e a r c h e r was able to e m p h a s i z e the s i g n i f i c a n c e o f the c o n t e x t w i t h i n w h i c h the i n d i v i d u a l has l i v e d a n d to show the i m p o r t a n c e o f the v a r i o u s groups or systems which  she has come i n t o c o n t a c t  knowledge  base  with  o v e r the years.  This  has e n r i c h e d the  i n the a r e a of t r a n s s e x u a l i s m a n d has a l l o w e d  for a shift  in  research f o c u s ( w h i c h , h i s t o r i c a l l y , has l a r g e l y i g n o r e d the e f f e c t o f the people a n d groups w h i c h s u r r o u n d the i n d i v i d u a l ) . A n e c o l o g i c a l m o d e l f o r assessment g u i d e d the c l a s s i f i c a t i o n o f the c r i t i c a l i n c i d e n t s r e v e a l e d d u r i n g the i n t e r v i e w process. i n t e r a c t i o n o f the i n d i v i d u a l w i t h a v a r i e t y s e r v e d to h i g h l i g h t standardized  T h e m o d e l , w h i c h e m p h a s i z e d the  o f groups w i t h i n  the e f f e c t o f i n t e r p e r s o n a l v a r i a b l e s .  instruments allowed  psychosocial functioning.  the e n v i r o n m e n t ,  T h e use o f the three  f o r a n assessment o f the i n d i v i d u a l ' s  current  T h e h i s t o r i c a l MMPI p r o f i l e s a l l o w e d a p o r t r a y a l  of  c h a n g e i n p s y c h o l o g i c a l f u n c t i o n i n g over the time span o f the tests. The  c o m p a r i s o n o f the three MMPI p r o f i l e s ( a d m i n i s t e r e d o v e r a s i x t e e n  year t i m e p e r i o d ) o f f e r e d a n o p p o r t u n i t y  to u n d e r s t a n d h o w t h i s i n d i v i d u a l has  d e v e l o p e d a n d c h a n g e d on the d i m e n s i o n s w h i c h t h i s i n s t r u m e n t  measures.  The  results o f t h i s s t u d y suggest a n u m b e r of issues w h i c h a p p e a r to have s i g n i f i c a n t l y i n f l u e n c e d the post o p e r a t i v e a d j u s t m e n t of t h i s person.  - 81 The Test Results A s reported in Chapter  the results o f the SSQ  IV,  s h o w e d the n u m b e r  of  s u p p o r t persons ( N score) l i s t e d across the s i t u a t i o n s p r e s e n t e d , r a n g e d f r o m 4 to 8 p e o p l e , w i t h a m e a n score of 5.7. their  research  with  T h e a u t h o r s r e p o r t e d a mean N score of 4.25 i n  a s a m p l e of  602 college  students.  With  reference  to  this  c o m p a r i s o n g r o u p , a l l that c a n be s a i d is that the case subject's m e a n N score is greater t h a n the m e a n o f the a u t h o r ' s sample.  L o o k i n g more c l o s e l y at the subject's  responses to s p e c i f i c q u e s t i o n s , one sees a c e r t a i n r e p e t i t i o n o f people l i s t e d .  This  suggests that, i n the case subject's o p i n i o n , there is a g r o u p of people w h o m she feels c o m f o r t a b l e t u r n i n g to, a n d also w h o m she feels may be r e l i e d u p o n across a variety  of  situations.  This  information  is consistent  with  information  gleaned  f r o m i n t e r v i e w s w i t h the f r i e n d s a n d f a m i l y o f the case subject. O n e of the persons i n t e r v i e w e d  d e s c r i b e d the e x p e r i e n c e o f f i r s t m e e t i n g  the case subject a n d b e i n g " c h e c k e d out" by the c i r c l e o f f r i e n d s o f that time.  It  was r e p o r t e d that there was a sense of h a v i n g to p r o v e o n e s e l f , not to the subject, but to her f r i e n d s . a n d how  O t h e r persons i n t e r v i e w e d also noted the role of  the subject  f r i e n d s a r o u n d her.  had always The M M P I  had a c i r c l e o f close, a n d at times  friendships protective,  p r o f i l e s , f r o m the e a r l i e s t a d m i n i s t r a t i o n o n w a r d ,  s u p p o r t the f i n d i n g that the subject d i d not v i e w h e r s e l f as b e i n g s o c i a l l y i s o l a t e d , i n spite o f w h a t e v e r other d i f f i c u l t i e s she m a y have h a d . During  the  process  of  the  interviews,  f r e q u e n t l y r e t u r n e d to the theme o f r e l a t i o n s h i p s . year  spent  cross-living  in  Toronto,  the  the  subject's  own  descriptions  In her d e s c r i p t i o n of 1971, the  isolation and  lack of  close  friendships  a p p e a r e d to p l a y a c r u c i a l role i n w h a t she d e s c r i b e d as p o s s i b l y the most d i f f i c u l t year of her l i f e .  T h e i m p o r t a n c e of w o r k a n d of b e i n g near people w h i l e at w o r k ,  was discussed a n d appears to have been a m e c h a n i s m f o r c o p i n g d u r i n g this p e r i o d .  - 82 In c o n j u n c t i o n  with  this, relatives  i n the T o r o n t o a r e a were  reported  to have  p r o v i d e d some e m o t i o n a l s u p p o r t a n d c o n t a c t d u r i n g t h i s p e r i o d o f t i m e . T h e s e d i f f e r e n t sources o f d a t a c o l l e c t i o n are a l l c o n s i s t e n t w i t h the results of the S S Q , s h o w i n g a n i n d i v i d u a l w h o enjoys a close a n d s u p p o r t i v e n e t w o r k o f relationships.  T h i s appears to be true not o n l y i n the present c o n t e x t , b u t also, to  h a v e been c o n s i s t e n t t h r o u g h the m a j o r i t y o f her a d u l t h i s t o r y . T h e Family Assessment Measure p r o v i d e d d a t a o n a v a r i e t y o f d i m e n s i o n s of f a m i l y f u n c t i o n i n g , not o n l y f r o m the case subject's p o i n t o f v i e w b u t f r o m those of the m o t h e r a n d the b r o t h e r as w e l l . In r a t i n g the f a m i l y as a w h o l e , the case subject scores the d i m e n s i o n s of C o n t r o l a n d A f f e c t i v e I n v o l v e m e n t as areas o f greatest s t r e n g t h .  T h e score f o r  A f f e c t i v e I n v o l v e m e n t suggests that the subject t h i n k s that w i t h i n the f a m i l y there is a sense o f e m p a t h y a n d e m o t i o n a l i n v o l v e m e n t .  T h e subscale C o n t r o l  i n t e r p r e t e d as a d i m e n s i o n o f a d a p t i v e n e s s f o r the subject.  is also  It is i n t e r e s t i n g to note  that the scores f o r A f f e c t i v e E x p r e s s i o n a n d C o m m u n i c a t i o n are i d e n t i c a l (50) a n d though hardly  p r o b l e m a t i c , are s t i l l not scored at a c o m p a r a b l e l e v e l o f s t r e n g t h ,  w h i c h the A f f e c t i v e I n v o l v e m e n t a n d C o n t r o l subscales a r e . A close i n s p e c t i o n o f these subscales suggests  t h a t , i n the case subject's o p i n i o n , t h i s f a m i l y  is more  e f f e c t i v e i n a c t i o n based d i m e n s i o n s t h a n i n v e r b a l l y based ones. The  dyadic  profiles  reveal  certain  r e l a t i o n s h i p s ( w h e n r a t e d by the case subject). brother  and father)  consistencies  the  In a l l three r e l a t i o n s h i p s  the C o m m u n i c a t i o n subscale  s t a n d a r d d e v i a t i o n a b o v e the m e a n .  across  is r a t e d  three  (mother,  at a p p r o x i m a t e l y  .5  T h e d i r e c t i o n o f these three scores suggests  that the subject feels that c o m m u n i c a t i o n between h e r s e l f a n d i n d i v i d u a l  family  m e m b e r s m a y not be as e f f e c t i v e as it c o u l d be. V a l u e s a n d N o r m s is not rated by the case subject as p r o b l e m a t i c w h e n she is f o c u s i n g on the o v e r a l l f a m i l y .  It is i n t e r e s t i n g that w h e n she is r e s p o n d i n g to  - 83 q u e s t i o n s r e g a r d i n g the c o m p o n e n t d y a d i c r e l a t i o n s h i p s , she rates t h i s d i m e n s i o n f r o m scores of 55 ( r e l a t i o n s h i p w i t h her m o t h e r ) to 60 ( r e l a t i o n s h i p s w i t h and w i t h brother). 60.  father  T h i s subscale, on the subject's self r a t i n g p r o f i l e , is scored at  T h e s e consistent e l e v a t i o n s i n d y a d i c scores, c o u p l e d w i t h the case subject's  self r a t i n g score, w o u l d suggest that she v i e w s c o m p o n e n t s o f her v a l u e system to be i n c o n f l i c t w i t h  those of  her f a m i l y .  In a p p a r e n t o p p o s i t i o n  to t h i s ,  r a t i n g the f a m i l y o v e r a l l she does not rate this subscale as p r o b l e m a t i c . explanation  is that  she rates the  family  as b e i n g r e l a t i v e l y  A possible  congruent  d i m e n s i o n , yet sees h e r s e l f as s o m e h o w d i f f e r e n t f r o m t h e m .  This  when  on  this  incongruence  does not t h e n become e v i d e n t u n t i l the d y a d i c r e l a t i o n s h i p s are e x a m i n e d .  This  h y p o t h e s i s is h i g h l y s p e c u l a t i v e a n d must be v i e w e d w i t h c a u t i o n ; h o w e v e r , it m a y possibly  relate  to  an  underlying  theme  of  'isolation  versus  belonging'  to  be  discussed later in this chapter. The  S e l f R a t i n g p r o f i l e shows the subject as r a t i n g 6 o f  the 7 subscales  w i t h i n 4 p o i n t s of the m e a n .  O v e r a l l , it w o u l d a p p e a r that she v i e w s her a b i l i t y to  function  s t r u c t u r e (as it c u r r e n t l y  within  the f a m i l y  problem free, with  the e x c e p t i o n of  exists) as b e i n g  the a f o r e m e n t i o n e d subscale of  relatively  Values  and  Norms. T h e c u r r e n t Minnesota Multiphasic Personality Inventory shows no s i g n i f i c a n t e l e v a t i o n s on c l i n i c a l scales.  T h i s is a d r a m a t i c c h a n g e w h e n c o m p a r e d w i t h  the  1971 p r o f i l e , w h i c h s h o w e d e l e v a t i o n s o f greater t h a n one s t a n d a r d d e v i a t i o n on Scales 2 & 3 a n d greater t h a n two s t a n d a r d d e v i a t i o n s on Scales 7, 8 & 9.  It is  i n t e r e s t i n g to note that the 1971 p r o f i l e s u p p o r t s the i n t e r v i e w d a t a , w h i c h stated that the h i g h relatively  level of social support  consistent  historically.  In  being measured c u r r e n t l y spite  of  an  elevated  by  Scale  the S S Q 8  was  (suggesting  s c h i z o i d a l t e n d e n c i e s ) the s o c i a l i n t r o v e r s i o n scale shows a score s l i g h t l y above the mean.  T h i s suggests that t h o u g h the subject m a y have been s p e n d i n g time alone  -84r u m i n a t i n g , a n d m a y h a v e f e l t u n a c c e p t e d by the w o r l d ( a n d p r o b a b l y  unaccepted  by h e r s e l f as w e l l ) she d i d not p e r c e i v e h e r s e l f as b e i n g s o c i a l l y i s o l a t e d . The introversion  1987 p r o f i l e  shows  a  lower  score  (raw  score  =  16) on  scale; h o w e v e r the s c h i z o i d a l t e n d e n c i e s are no l o n g e r  the  in  social  evidence.  T h e scale 5 ( m a s c u l i n i t y / f e m i n i n i t y ) , b e i n g e l e v a t e d s l i g h t l y b e y o n d one s t a n d a r d d e v i a t i o n , suggests that the subject is not a n s w e r i n g the q u e s t i o n s of t h i s subscale in a stereotypical f e m i n i n e fashion. integration  into  the  feminine  T h i s does not n e c e s s a r i l y c a l l the  role  into  question;  i n t e g r a t i o n is not based on t r a d i t i o n a l stereotypes.  it  does  show  that  subject's the  role  C o n s i d e r i n g the c o n t e n t of this  scale, a score i n the ' f e m i n i n e ' d i r e c t i o n w o u l d be o f q u e s t i o n a b l e a d a p t a b i l i t y at this t i m e i n o u r s o c i e t y .  T h i s too is a d r a m a t i c c h a n g e f r o m the  1971 p r o f i l e  w h i c h s h o w e d the subject s c o r i n g at the 97th p e r c e n t i l e o f t h i s scale. In s u m m a r y , the s t a n d a r d i z e d person w h o  tests h a v e  portrayed  the case subject  is: (1) s o c i a l l y i n t e g r a t e d ; (2) feels a f f e c t i o n a n d e m p a t h y  as a  with  her  f a m i l y o f o r i g i n , t h o u g h she m a y have d i f f i c u l t y e x p r e s s i n g i t ; (3) f e e l s s o m e w h a t apart  from  her  family  on  issues of  certain  basic  values;  (4)  demonstrates  no  e v i d e n c e o f m e n t a l i l l n e s s ; (5) appears to d e r i v e p l e a s u r e f r o m l i f e ; (6) is n e i t h e r e x c e s s i v e l y s e x - r o l e s t e r e o t y p e d nor e x c e s s i v e l y  counter-stereotyped.  The C r i t i c a l Incidents In r e v i e w i n g the c r i t i c a l i n c i d e n t s , w h a t is most s t r i k i n g is that of the 30 i n c i d e n t s r e p o r t e d , 22 o f c o n f i r m s an u n d e r l y i n g exists a n d  interacts w i t h  t h e m f a l l u n d e r the c l a s s i f i c a t i o n , " C o m m u n i t y . " assumption of a variety  of  this research project:  This  that the  individual  i n d i v i d u a l s a n d g r o u p s , a l l of  w h i c h , to  v a r y i n g degrees, e x e r t an i n f l u e n c e u p o n the i n d i v i d u a l . T h e i n c i d e n t s c a n be i n t e r p r e t e d on s e v e r a l levels.  When c l a s s i f i e d on the  basis o f the sub-systems i n v o l v e d , the reader is able to see the i m p a c t of separate  - 85 g r o u p s , a l l o f w h i c h were s i g n i f i c a n t to the case subject at d i f f e r e n t times i n her life. the  T h i s e m p h a s i s is an i m p o r t a n t one because it h i g h l i g h t s the s i g n i f i c a n c e context  within  which  the  individual  c r e a t e d a s p e c i f i c set o f needs or wishes. reassignment. important.  exists.  The  subject's  of  transsexualism  A n e x a m p l e of this was the w i s h f o r sex-  A s a result o f this w i s h / n e e d , c e r t a i n s u b - s y s t e m s became e x t r e m e l y  R e p r e s e n t a t i v e s of the m e d i c a l c o m m u n i t y , w i t h t h e i r p o w e r to support  or not s u p p o r t the i n d i v i d u a l ' s goal o f s e x - r e a s s i g n m e n t , c a m e to h a v e c o n s i d e r a b l e significance.  Inspection  the  case  subject was l a r g e l y s u p p o r t e d by the p h y s i c i a n s w h o m she c a m e i n t o c o n t a c t  with  p r i o r to s u r g e r y .  of  the i n c i d e n t s  in  this c a t e g o r y  reveal  that  What seems i m p o r t a n t is that none o f the m e d i c a l p r o f e s s i o n a l s  a p p e a r to h a v e q u e s t i o n e d the seriousness o f her request.  T h o u g h the process was a  l o n g a n d f r u s t r a t i n g one, it was not f i l l e d w i t h the diagnoses o f d e l u s i o n a l states, r i d i c u l e or i n d i f f e r e n c e , w h i c h at times have been r e p o r t e d i n the l i t e r a t u r e , (e.g., B o g d e n , 1974; M a s o n , 1980) The  e f f e c t o f the case subject's p r e - o p e r a t i v e  c h a r a c t e r i s t i c s (i.e.  feminine  c h a r a c t e r i s t i c s ) on other people, a n d as a result, t h e i r r e c i p r o c a l e f f e c t on her, arc clearly shown  i n the i n c i d e n t w i t h  the g r a d e 9 teacher ( i n c i d e n t  T h o u g h s c h o o l h a d a l w a y s e n g e n d e r e d c e r t a i n d i f f i c u l t i e s , s u c h as  #9, table 4.1). p e r i o d i c teasing  f r o m c l a s s m a t e s , u n t i l grade 9 it h a d been a b e a r a b l e , i f not pleasant ( a c c o r d i n g to r e t r o s p e c t i v e d e s c r i p t i o n s ) . to this t i m e .  experience  N o a c a d e m i c p r o b l e m s were e v i d e n t  prior  B e g i n n i n g i n this y e a r , a n d c o n t i n u i n g i n the two years that f o l l o w e d ,  the subject's d i f f i c u l t i e s i n school e s c a l a t e d , as d i d her d e s i r e to leave a n d a t t e n d trade school.  R i d i c u l e f r o m the  grade 9 teacher, a n d then a g a i n i n  g r a d e 10 (the  same t e a c h e r t a u g h t both years) appears to have been p i v o t a l , i n terms of a t t i t u d e s toward  school.  R i d i c u l e f r o m classmates also p e a k e d d u r i n g  a p p e a r s to have s u b s i d e d h o w e v e r ,  after  this p e r i o d .  This  i n c i d e n t #24 (see table 4.1) in w h i c h a  f a m i l y f r i e n d spoke to a n u m b e r of n e i g h b o r h o o d c h i l d r e n about the case subject  - 86 'being  different.'  It  was  not  u n t i l a suicide attempt  at age  f i f t e e n , and  the  r e s u l t i n g v i s i t s to the school p s y c h o l o g i s t , that the teacher's b e h a v i o r was m o d i f i e d . By  this  t i m e the subject  would  not  be s w a y e d  from  her  decision  to stop  her  secondary education and commence attending trade school in Toronto. It was also t o w a r d the end of t h i s p e r i o d (1963) that the t h e n f i f t e e n y e a r old  case  subject  saw  Christine  Jorgenson  (a  post  operative  male-to-femalc  t r a n s s e x u a l ) on t e l e v i s i o n , a n d began to seek i n f o r m a t i o n a b o u t the p r o c e d u r e sex-reassignment.  of  T h e s e t w o goals, f o r m e d by about age f i f t e e n became p r i m a r y ,  a n d r e m a i n e d c o n s t a n t u n t i l the s u c c e s s f u l c o m p l e t i o n o f e a c h . A t t e n d i n g t r a d e s c h o o l to s t u d y h a i r s t y l i n g f o r m a l i z e d a n d gave s a n c t i o n to an a c t i v i t y Incidents  the case subject had done (and  #15  through  been p a i d f o r ) since her e a r l y  #22 are f o c u s e d i n the area o f  vocation.  Incident  o c c u r s at a b o u t age f o u r t e e n , w h e n the subject f i r s t began to be p a i d f o r hair.  T h i s e f f e c t i v e l y was the b e g i n n i n g o f her career.  teens. #15  cutting  B y age t w e n t y , the subject  had b o u g h t her o w n s a l o n i n the t o w n w h e r e she g r e w up.  D u r i n g the  interviews  this was d e s c r i b e d as a t i m e o f some s o c i a l i s o l a t i o n , yet, a t i m e of v o c a t i o n a l and f i n a n c i a l success.  It  was also d u r i n g  this p e r i o d that  the subject  h i s t o r i c a l h a i r a n d f a s h i o n show w h i c h was r e c e i v e d f a v o r a b l y the p u b l i c .  organized  an  by the press and  T h e y o u n g m a n w h o years b e f o r e h a d been r e f u s e d a request to take  s e w i n g i n s c h o o l h a d staged a s u c c e s s f u l f a s h i o n s h o w ( s e w i n g the clothes h i m s e l f ) i n the c o m m u n i t y w h i c h had p r e v i o u s l y c e n s o r e d h i m f o r his a t y p i c a l b e h a v i o r . T h e subject then entered a p r o v i n c i a l h a i r s t y l i n g c o m p e t i t i o n . i n three c a t e g o r i e s , w i n n i n g recognition  within  i n two  and placing third  his trade a n d o f f e r s  r e s u l t e d i n a d e c i s i o n to move  of  work  to R e g i n a a n d  in  the  p e r s o n a l c o n n e c t i o n s w h i c h r e m a i n i n t a c t to this d a y .  i n one.  more forging  With  urban of  H e entered this came  centers.  This  professional  and  -87D u r i n g the i n t e r v i e w s the case subject s a i d that as a teenager her a b i l i t y to cut h a i r a n d to sew gave her a w a y to b u i l d r e l a t i o n s h i p s w i t h peers.  One incident  (#24), i n w h i c h the a d u l t f a m i l y f r i e n d spoke to her o w n son a n d his f r i e n d s about the t e a s i n g of  the case subject,  supports  this  to a n e x t e n t .  It  was  after  this  i n c i d e n t , that the boys are r e p o r t e d to have ceased t e a s i n g .  T h e subject e x p l a i n e d  that once  this  the t e a s i n g s t o p p e d , she became f r i e n d l y  sewing for  them and  cutting  their  hair.  Even  if  with this  group and  interpretation  began  (that  f o u n d a t i o n o f those r e l a t i o n s h i p s was at least p a r t i a l l y based i n the s e r v i c e  the  which  the subject p r o v i d e d ) is i n c o r r e c t , it is i m p o r t a n t that she s t i l l p e r c e i v e s that her offering  of  these s k i l l s  served  as a s p r i n g b o a r d  for  the  development  of  these  friendships. B e g i n n i n g at trade s c h o o l i n T o r o n t o , f r i e n d s h i p s o f a s o m e w h a t n a t u r e are r e p o r t e d .  different  D u r i n g this t i m e , the r e l a t i o n s h i p s a p p e a r based on a m u t u a l  interest i n h a i r s t y l i n g as w e l l as other a c t i v i t i e s s u c h as m u s i c , g o i n g to c a f e s , etc. r a t h e r t h a n i n the o f f e r i n g o f s k i l l s or services.  T h e case subject r e p o r t e d that it  was i n T o r o n t o w h e r e she f i r s t f e l t that she d i d not s t a n d out a n d was free to act as she pleased. reported  Later, in  this  understood  same  about  sense  "being  Regina, while of  not  s o c i a l i z i n g i n the gay  standing  different."  This  out,  and  initial  of  community,  meeting  involvement  people  with  the  she who gay  c o m m u n i t y was p r c - o p e r a t i v e , a n d o c c u r r e d p r i o r to the subject's c o m m e n c e m e n t of c r o s s - l i v i n g . She stated that  though  the  individual  ones, she d i d not c o n s i d e r h e r s e l f to be h o m o s e x u a l .  relationships  were  cmpathic  T h i s is c o n s i s t e n t w i t h  reports  expressed i n the r e s e a r c h that t h o u g h the s e x u a l o r i e n t a t i o n m a y be h o m o s e x u a l or h e t e r o s e x u a l , it  is the gender  orientation  which  is p r i m a r y  i n the  project,  the subject  and  individual's  d e f i n i t i o n o f self (e.g. S t e i n e r , 1985). During  the t i m e o f  this research  made the d e c i s i o n to l i v e ' c o m m o n - l a w . '  her  boyfriend  F o r the subject, this i n v o l v e d not o n l y a  - 88 c o m m i t m e n t to the r e l a t i o n s h i p , but also to the r e s p o n s i b i l i t i e s of b e i n g a parent: the p a r t n e r marriage.  b r o u g h t to the r e l a t i o n s h i p  a three-year  o l d son f r o m  his  previous  T h o u g h he h a d c u s t o d y of the c h i l d at the t i m e o f the d e c i s i o n to c o -  h a b i t a t e , a c u s t o d y d i s p u t e w i t h the b i o l o g i c a l m o t h e r ensued. F o r the case subject, this i n v o l v e d her t r a n s s e x u a l i s m e f f e c t i v e l y b e i n g ' h e l d up to p u b l i c s c r u t i n y , ' as her f i t n e s s to be a p a r e n t (as w e l l as that o f the father)  was a r g u e d  by  representatives  of  the f a m i l y  court  system.  It  was  d e c i s i o n of the c o u r t to a w a r d t e m p o r a r y c u s t o d y to the subject a n d boy's a n d to r e v i e w the case a g a i n i n one year.  boy's the  father,  It is n o t e w o r t h y that i n the r e p o r t to the  c o u r t ( c o m p i l e d by the s o c i a l w o r k e r w h o had s t u d i e d b o t h home e n v i r o n m e n t s ) , it was stated that the subject was p e r c e i v e d to be a b l e to p r o v i d e c h i l d , a n d d e m o n s t r a t e d a c l e a r a b i l i t y to parent.  stability for  the  H e r t r a n s s e x u a l i s m was seen by  the s o c i a l w o r k e r , a n d u l t i m a t e l y by the c o u r t , not to be a b a r r i e r to f u l f i l l i n g the m a t e r n a l role.  The Situational Influences T a b l e 4.3 consists of interview  process.  They  11 o n g o i n g i n f l u e n c e s or issues u n c o v e r e d have  c l a s s i f i c a t i o n scheme used w i t h  been  classified  using  the c r i t i c a l i n c i d e n t s .  the  same  during  the  eco-systemic  What d i f f e r e n t i a t e s  these  ' i n f l u e n c e s ' f r o m the c r i t i c a l ' i n c i d e n t s ' is t h e i r l a c k of o b v i o u s b e g i n n i n g a n d end points. O f the 11 i n f l u e n c e s c i t e d , 6 (55%) of t h e m are c l a s s i f i e d at the " I n d i v i d u a l " level.  A l t h o u g h these i n f l u e n c e s a p p e a r d i v e r s e a n d v a r i e d , it is n o t e w o r t h y  that  this l a r g e a p r o p o r t i o n of t h e m are at this l e v e l o f c l a s s i f i c a t i o n , whereas o n l y 4 of 30 ' i n c i d e n t s ' were c l a s s i f i e d at this l e v e l . s t y l e , or w a y of b e i n g .  T h e s e i n f l u e n c e s a p p e a r to relate to a  I n f l u e n c e #1 (the l a c k o f a t h l e t i c s k i l l s a n d r e s u l t i n g time  spent alone) a n d i n f l u e n c e #2 ( l e a r n i n g to sew a n d later to cut h a i r )  r e s u l t e d in  - 89 the d e v e l o p m e n t  o f s k i l l s w h i c h i n t u r n appear to have later f a c i l i t a t e d  r e l a t i o n s h i p s (or so the case subject  believes).  The  teenage  r e a l i z a t i o n that openness and  h o n e s t y , w i t h s i g n i f i c a n t others, c o u l d have p o s i t i v e results ( i n f l u e n c e #3), lead to d i s c l o s u r e s ( p r e - o p e r a t i v e l y ) o f the desire f o r s e x - r e a s s i g n m e n t (and r e s u l t i n g f r o m that d i s c l o s u r e , f a m i l y s u p p o r t f o r the process, [ i n f l u e n c e  #7]).  F r o m the d a t a a v a i l a b l e we c a n n o t t e l l i f i n f l u e n c e #6 is t r u l y a n i n f l u e n c e or a result (i.e. d i d the d e p r e s s i o n result i n v o c a t i o n a l i n s t a b i l i t y a n d a l c o h o l a n d drug  a b u s e , or  depressive  vice-versa?).  We also are  not  able  to assess the degree  of  the  types  of  symptomology.  The  "Community"  relationships.  level  influences  are  focused  on  various  T h e f o r g i n g o f f r i e n d s h i p s w i t h i n the c o n t e x t of the gay c o m m u n i t y  of R e g i n a ( i n f l u e n c e #8) a l l o w e d f o r the d e v e l o p m e n t o f c m p a t h i c f r i e n d s h i p s a n d f e e l i n g s o f b e l o n g i n g , yet also of b e i n g a p a r t . she t h o u g h t that her f r i e n d s u n d e r s t o o d clear  to  her  that  she  was  not  A l t h o u g h the subject r e p o r t e d  that  her f e e l i n g s of ' b e i n g d i f f e r e n t , ' it was  homosexual  and  as  a result  would  never  feel  c o m p l e t e l y a p a r t o f this c o m m u n i t y . T r a n s s e x u a l s a n d h o m o s e x u a l s , a l t h o u g h s h a r i n g the c h a r a c t e r i s t i c of b e i n g s e x u a l m i n o r i t i e s , are c l e a r l y not the same p h e n o m e n o n .  This common factor  m i n o r i t y status m a y serve to f a c i l i t a t e a c c e p t a n c e of each oth er, yet it w o u l d  of not  (and d i d not, f o r the case subject), result i n the e r a d i c a t i o n o f t h e i r d i f f e r e n c e s . Influences acknowledges  as  behavior.  This  importance  of  #9  and  having is  #10 had  a great  consistent  having  represent  with  meaningful  relationships  enough other  impact  data  relationships.  which to  gathered In  a  result  in  which less  i n f l u e n c e #11 c o u l d also be r e l a t e d to this issue of r e l a t i o n s h i p s . b e i n g ' r e a d ' due to the q u a l i t y  the  of her v o i c e , c o u l d c o n c e i v a b l y  case  subject  a change highlight  obvious  of the  manner,  T h e f e e l i n g of cause e i t h e r  the  - 90 subject or  the person  w h o m she f e l t ' r e a d ' by  to w i t h d r a w ,  thereby  negatively  a f f e c t i n g the f o r m a t i o n of that ( p r o b a b l y t r a n s i t o r y ) r e l a t i o n s h i p . In s u m m a r y , the i n f l u e n c e s c i t e d here appear to r e v o l v e a r o u n d t w o p r i m a r y issues.  T h o s e i n f l u e n c e s c l a s s i f i e d at the I n d i v i d u a l  l e v e l relate s t r o n g l y  subject's i n d i v i d u a l style or w a y o f b e i n g i n the w o r l d . Family  and  Community  levels  relate  to  the  to the  T h o s e c l a s s i f i e d at the  formation  and  maintenance  of  A s stated at the outset, the e c o - s y s t e m i c c l a s s i f i c a t i o n scheme served  to  d i f f e r e n t types o f i n t e r p e r s o n a l r e l a t i o n s h i p s .  Underlying  highlight  Themes  the  importance of  the c o n t e x t  in  which  the  individual  lives.  When  l o o k i n g at the i n c i d e n t s c o l l e c t i v e l y t h o u g h , it appears that there are s e v e r a l more g e n e r a l themes u n d e r l y i n g the c l a s s i f i c a t i o n scheme. T h e s e themes c e n t r e on issues of: a c c e p t a n c e versus r e j e c t i o n , i s o l a t i o n versus b e l o n g i n g , a n d c o m p e t e n c y incompetency.  Acceptance  as  the  woman,  by  affirmation  v o c a t i o n a l l y , or  i n roles, such as that o f ' m o t h e r ; ' a n d  to be a p a r t a n d d i f f e r e n t  individual's  society  representatives;  always  of  a  from  and  competency,  others, are  its whether  versus  individual that  be  the need to b e l o n g ,  not  themes w h i c h  permeate  the  incidents and influences cited. T h e c h o i c e to l i v e c o m m o n - l a w a n d to take on the role o f p a r e n t , a n d then the e n s u i n g themes.  custody  dispute, may  be seen as i n v o l v i n g  all of  these  individual  In the s i x t h i n t e r v i e w , w h i c h was f o c u s e d on the a r e a o f ' r o m a n c e , ' the  i n v e s t i g a t o r q u e s t i o n e d the subject about the m e a n i n g o f , a n d reasons f o r , t a k i n g on the roles o f w i f e a n d m o t h e r .  T h o u g h a n u m b e r o f issues r e l a t i n g to f e e l i n g s of  l o v e a n d c a r i n g were d i s c u s s e d , the subject s a i d also that it was the f u l f i l l m e n t of a n d o l d d r e a m : the d r e a m o f b e c o m i n g w i f e a n d m o t h e r .  - 91 The theme of 'belonging' is intrinsically tied to this dream of becoming a wife and mother. Fulfilling the roles of wife and mother within a nuclear family can be interpreted as having a place (i.e. the family) where one belongs.  The  custody dispute can be seen as a challenge to the subject's legitimacy in these roles. Ultimately, it is the court report and  custody  disposition which demonstrates  society's acceptance of this individual as a woman, and  its statement of her  competence as a mother. For a complete classification of the critical incidents according to these themes, please see Appendix E.  Research Questions: Conclusions  What are  the  significant factors in the  post operative adjustment of  a  male-to-  female transsexual?  A total of 30 critical incidents were revealed during the data collection process. The Classification Table of Critical Incidents (Table 4.1) shows that the "Individual" and  "Family" levels contain 4 incidents each.  The  remaining  22  incidents are classified in one of the sub-sections of the "Community" level. While not negating the importance of any one of these sources, the significance of subsystems at the community level is emphasized by the number of incidents which fall into this category.  Within the Community level, 8 incidents (40% of the total  number) are seen in the sub-section entitled "Vocational." Having the ability to be self supporting, as well as being recognized as skilled, appears to relate to an ongoing theme of competency.  In conclusion, this initial research question is  answered by inspection of the individual critical incidents. It seems important though, to discuss this question with attention not only to the specific incidents but also to the pattern which they form.  -92W h a t a r e the consequences o f these f a c t o r s , a n d w h y are t h e y seen as s i g n i f i c a n t i n the subject's post o p e r a t i v e a d j u s t m e n t ?  The consequences of these factors (incidents) are listed under the "Result" section of Table 4.1.  They were classified as significant as a result of meeting two  primary criteria: they were considered to be significant by the case subject, and they resulted in an observable change of some type (a behavior, an event, etc.) which could be related to the case investigator.  These two points of view (i.e. the  case subject's perception of significant events in her own life, and the researcher's desire to anchor the incidents in observable and verifiable phenomena) were not always in agreement.  The requirement that 'significance' be agreed upon, and meet  the criteria of both the investigator and the subject, ultimately allowed for the generation of a series of incidents which satisfied both. A m o n g f a c t o r s i d e n t i f i e d as s i g n i f i c a n t , w h a t is t h e i r o r d e r o f s i g n i f i c a n c e ?  The exploration of this final question proved to be an interesting exercise. The correlation of the two sets of ratings showed that the level of agreement was not particularly strong (r = .55).  The statistic used measured only the level of  agreement/disagreement between the case investigator and case subject and did not account for the degree or magnitude of the discrepancy.  For example, of the ten  incidents rated at level 4, the subject and investigator rated six of them the same. The remaining four of the incidents rated at this level by the case subject can be found rated by the investigator at level 3.  Of the remaining four incidents rated  by the investigator at level 4, three of them can be found in the case subject's rating of level 3. somewhat less.  As one looks at these ratings, the level of disagreement appears It does not, however, change the result of this section of data  analysis; there is considerable disagreement between subject and investigator about which factors were most significant.  When looking at the level 3 and level 4  discrepancies, an argument can be made that perhaps the distinction between these  -93levels was not c l e a r . explain  It is d o u b t f u l , h o w e v e r , that t h i s e x p l a n a t i o n c a n be used to  all differences  between  ratings.  With  e x p l a n a t i o n s o f this result r e m a i n e l u s i v e . the  disagreement  resides  within  the d a t a  available,  conclusive  It is a p o s s i b i l i t y t h o u g h , that m u c h of  different  perceptions  of  what  c o n s t i t u t e s the  ' s i g n i f i c a n c e ' o f a n i n c i d e n t (i.e. the i n v e s t i g a t o r ' s need f o r a t a n g i b l e result a n d the subject's s u b j e c t i v e u n d e r s t a n d i n g o f the i n t a n g i b l e results o f i n c i d e n t s ) .  The Results Within T h e Context O f Other Research It is i n t e r e s t i n g a n d i m p o r t a n t to l o o k at this project w i t h i n the c o n t e x t o f past s t u d i e s .  T h e i n t e n s i v e case s t u d y m e t h o d used here has g e n e r a t e d a mass o f  d a t a , w h i c h is b r o a d e r i n scope t h a n the r e s e a r c h q u e s t i o n s have r e q u i r e d .  This  s e c t i o n o f the s t u d y  past  empirical work  t h e r e f o r e looks at the r e l a t i o n s h i p o f t h i s p r o j e c t  with  by f o c u s i n g not o n l y on the research q u e s t i o n s , but on the d a t a  base as a w h o l e . E v i d e n c e o f i n c r e a s e d levels o f self esteem (post o p e r a t i v e l y ) MMPI p r o f i l e s  is i n k e e p i n g w i t h  M a c k e n z i e (1981). profiles  supports  improvements instrument.  The overall the w o r k  following What  of  the f i n d i n g s  improvement Fleming  sex-reassignment  this s t u d y  of Ball  (1981) a n d S k a p c c a n d  i n p r e - a n d post  et a l . , (1981) in  the  went o n to suggest  f o u n d i n the  o p e r a t i v e MMPI  who showed  profile  generated  by  this  is that the i m p r o v e m e n t m a y  c o n t i n u e o v e r a l o n g p e r i o d o f t i m e , as e v i d e n c e d by the c h a n g e f r o m 1987 p r o f i l e s .  significant  1975 a n d  S i n c e no studies were f o u n d i n the l i t e r a t u r e that s t u d i e d the MMPI  d i m e n s i o n s (post o p e r a t i v e l y ) over a c o m p a r a b l e l e n g t h o f t i m e , it c a n n o t be stated with  certainty  individual.  whether  this is a s i g n i f i c a n t  trend  or a result  peculiar  to this  M e y e r a n d R e t e r (1979) d i d s h o w that i n a l l three o f the groups they  s t u d i e d ( o p e r a t e d , u n o p e r a t e d a n d s u b s e q u e n t l y o p e r a t e d ) , there was g e n e r a l to p s y c h o l o g i c a l a n d s o c i a l i m p r o v e m e n t , w h i c h  is s i m i l a r to the present  trend result.  -94The lack of data to resolve this question definitively points out the need for ongoing follow-up and the tracking of these individuals, post operatively, over years (rather than months, which is the more common case). The loneliness and isolation of adolescence reported in the interviews is echoed in the writings of the female-to-male transsexual, Mason (1980). The later frustration experienced by the case subject in seeking sex-reassignment  closely  parallels the experiences of Shumaker (Levine and Shumaker, 1983). Unlike the finding of Lothstien (1980), all evidence suggests that for this individual there is a consistent history of meaningful and supportive relationships. This current finding is also at odds with other studies, which show social isolation pre-operatively, followed by a lessening of such post operatively (Fleming et al., 1981; Fleming, MacGowan, Robinson, Spitz & Salt, 1982). The relative consistency of the case subject's social integration is an unusual finding. As stated in the review of the research literature, relatively few studies have focused on the contextual operative adjustment.  and interpersonal variables which affect  post  Hastings and Markland (1978) found that the area of  'romance' tended to be an area of ongoing difficulty for many post operative individuals.  The data gathered here suggested a history of at least two severely  troubled relationships, one of which appears to have predicated a suicide attempt (incident #4). Notwithstanding periodic romantic difficulties, the case subject would now rate as 'successful' on any of the outcome scales known to this researcher (e.g. Hastings and Markland, 1978; Hunt and Hampson, 1980).  As might be predicted  from the results of Walinder, Lundstrom and Thuwe's research (1978), none of the contraindicators they found were present in the pre-operative history of the case subject. The one exception to this was the geographic distance between therapist and patient, which the case subject resolved by moving to Toronto.  -95T h i s project  f o l l o w s i n the t r a d i t i o n o f a s m a l l n u m b e r o f s t u d i e s  which  h a v e h i g h l i g h t e d a n d posed questions about the e f f e c t of the e n v i r o n m e n t on the individual.  T h i s group of  studies w o u l d  include Levine  a n d S h u m a k e r (1983),  M a s o n (1980), Oles (1977), a n d Y a r d l e y (1976). O l e s (1977), i n her d i s c u s s i o n of p s y c h o t h e r a p u t i c issues, states t h a t the area of e m p l o y m e n t is a n i m p o r t a n t a n d o f t e n d i f f i c u l t one f o r t r a n s s e x u a l people. a n e x a m p l e , she p o i n t s to the d i l e m m a o f w h e t h e r or not the i n d i v i d u a l s d i s c l o s e t h e i r t r a n s s e x u a l i s m to e m p l o y e r s .  may  find  should  In her o p i n i o n , i f the person discloses,  t h e y r i s k b e i n g f i r e d ( w h i c h h a p p e n e d to the case subject i n T o r o n t o ) . not d i s c l o s e , they  As  themselves l i v i n g  in  fear  of  If they do  being discovered  (an  e x p e r i e n c e also r e l a t e d by the case subject). Y a r d l e y (1976) h y p o t h e s i z e s that a c c e p t a n c e by the t h e r a p i s t o f the crossgender d e s i r e o f the p a t i e n t , is a p o s i t i v e p r o g n o s t i c i n d i c a t o r . elaborate further subject  did  on t h i s h y p o t h e s i s .  report  a  belief  that  In the  Y a r d l e y does not  the d a t a c o l l e c t i o n f o r relationship  between  this s t u d y ,  herself  the  and  her  p s y c h i a t r i s t at the C l a r k e I n s t i t u t e had a s i g n i f i c a n t p o s i t i v e i m p a c t w h i l e she was i n the stage o f c r o s s - l i v i n g . " c h a l l e n g e d to succeed."  T h e subject d e s c r i b e d t h i s i m p a c t as a f e e l i n g of b e i n g  Without  more e l a b o r a t i o n of Y a r d l e y ' s  hypothesis  it is  d i f f i c u l t to k n o w i f t h i s b e l i e f (of the case subject) is i n s u p p o r t of it. R e s u l t s o f t h i s s t u d y a p p e a r to be consistent w i t h the d e s c r i p t i o n of M a s o n (1980), w h o  stated that  the c l i e n t ' s f e e l i n g s of  b e i n g a c c e p t e d by  a n d / o r c l i n i c a l team leads to i n c r e a s e d f e e l i n g s of self esteem.  the  In  therapist  retrospective  d e s c r i p t i o n s , the case subject d e s c r i b e d how a n y response f r o m r e p r e s e n t a t i v e s  of  the m e d i c a l c o m m u n i t y , w h i c h a c k n o w l e d g e d her d i a g n o s i s as t r a n s s e x u a l (even i f the response i t s e l f was not p o s i t i v e ) e n c o u r a g e d her to c o n t i n u e to seek S R S . the d a t a a v a i l a b l e we c a n n o t say p o s i t i v e l y d e m o n s t r a t e increases i n self  esteem.  that these r e t r o s p e c t i v e  It does a p p e a r  however,  that  From  descriptions feelings  of  -96b e i n g e n c o u r a g e d a n d a f f i r m e d are b e i n g d e s c r i b e d a n d that these m a y be r e l a t e d i n some w a y to increases i n self esteem. T h e r e was no suggestion here that the case subject p l a c e d s i m i l a r c o n s t r a i n t s a n d l i m i t s on the t h e r a p u t i c r e l a t i o n s h i p (due to the a b i l i t y of the p s y c h i a t r i s t to r e c o m m e n d f o r or against S R S ) as was d e s c r i b e d by L e v i n e a n d S h u m a k e r (1983).  Limitations of the Study T h i s s t u d y has d e s c r i b e d the e x p e r i e n c e o f a n i n d i v i d u a l . be  generalized.  It  has  provided  a portrayal  of  the  The data cannot  psychological  and  social  a d j u s t m e n t o f one t r a n s s e x u a l . U n l i k e f o r m s o f research w h i c h a t t e m p t to generate i n f o r m a t i o n w h i c h c a n be g e n e r a l i z e d to a p o p u l a t i o n , this mode of research p r o v i d e s i n - d e p t h of one person.  This methodology  has succeeded i n p r o v i d i n g  knowledge  d e t a i l s about  one  case, a n d g e n e r a t i n g q u e s t i o n s to ask across a l a r g e r s a m p l e o f t r a n s s e x u a l people. T h e use of a n u m b e r of sources of d a t a c o l l e c t i o n ( h i s t o r i c a l r e c o r d s  and  test scores, i n t e r v i e w s w i t h f a m i l y a n d f r i e n d s , case subject i n t e r v i e w s a n d c u r r e n t test scores) increases c o n f i d e n c e i n the v a l i d i t y a n d i n the r e l i a b i l i t y o f the results. Conclusions  regarding  strengthened  had  made available.  the  subject's  historical  more d e t a i l e d case r e c o r d i n g s  functioning  would  f r o m the C l a r k e  have  Institute  been been  U n f o r t u n a t e l y , this was not possible.  This study  is a f o u n d a t i o n u p o n  w h i c h , by the process o f  answering  the  q u e s t i o n s it raises, a n d c o n f i r m i n g or d i s p u t i n g its f i n d i n g s , a s i g n i f i c a n t b o d y of knowledge  in  the  area  of  post  operative  transsexualism  V i e w e d i n i s o l a t i o n , the results are h i g h l y l i m i t e d . h y p o t h e s e s , a n d of q u e s t i o n s f o r project becomes c l e a r .  future  may  be  constructed.  V i e w e d as a source o f d a t a , of  research p r o j e c t s , the u s e f u l n e s s of  the  -97Implications and Suggestions For Future Research The  number of .critical incidents  which  were  found  at the  "Community"  l e v e l o f the c l a s s i f i c a t i o n scheme suggests that research needs to address the i m p a c t of  negative  and  positive  responses  from  these  specific  groups  (e.g.  medical  c o m m u n i t y , f r i e n d s , etc.) on p s y c h o s o c i a l f u n c t i o n i n g at the p r e - o p e r a t i v e , as w e l l as post o p e r a t i v e stages.  T h e hypotheses put f o r t h by Y a r d l e y (1976) r e g a r d i n g the  e f f e c t on o u t c o m e , of a c c e p t a n c e by the t h e r a p i s t o f the t r a n s s e x u a l ' s desire s e x - r e a s s i g n m e n t , r e m a i n s untested.  for  In this s t u d y , w h a t a p p e a r s to have been a  p o s i t i v e t h e r a p e u t i c a l l i a n c e between the case subject a n d her p s y c h i a t r i s t was, in the case subject's o p i n i o n , b e n e f i c i a l i n terms of self c o n f i d e n c e a n d d e t e r m i n a t i o n to o v e r c o m e  obstacles.  The  e f f e c t of d i f f e r e n t  therapist/client  r e l a t i o n s h i p s on  h a b i l i t a t i o n a n d o u t c o m e i n the post o p e r a t i v e gender r o l e , r e m a i n s a n i m p o r t a n t b u t u n c h a r t e d area o f s t u d y w i t h this p o p u l a t i o n . O u t c o m e s t u d i e s , i n t h e i r attempts to measure the degree o f post o p e r a t i v e success or f a i l u r e , u s u a l l y i n c l u d e some r a t i n g of e m p l o y m e n t f u n c t i o n i n g . project  This  has suggested that the m e a n i n g o f e m p l o y m e n t t r a n s c e n d s — a n d is m u c h  more c o m p l e x — t h a n an a b i l i t y to be s e l f - s u p p o r t i n g . c a r e e r success appears to have i n c r e a s e d f e e l i n g s o f  F o r the person s t u d i e d here, c o n f i d e n c e a n d self  worth  ( a f t e r a c h i l d h o o d m a r k e d by episodes o f r i d i c u l e a n d p e r v a s i v e f e e l i n g s of b e i n g ' d i f f e r e n t ' a n d 'odd').  T h e e f f e c t o f e m p l o y a b i l i t y a n d c a r e e r s u c c e s s / f a i l u r e on  s u c h d i m e n s i o n s as self image (both p r e - a n d post o p e r a t i v e l y ) possible s t u d y .  is a n o t h e r area of  T h i s also w o u l d suggest that research i n the area o f  counselling, and into what  the s p e c i f i c needs o f  this population  vocational  m a y be,  would  seem a v a l u a b l e a r e a of s t u d y . I m p r o v e d s o c i a l a n d f a m i l i a l i n t e g r a t i o n a n d a c c e p t a n c e , post o p e r a t i v e l y , is a c o m m o n but not u n i v e r s a l f i n d i n g i n the l i t e r a t u r e . sense of ' b e l o n g i n g ' appears to be a p r i m a r y  T h e s t r u g g l e f o r an o n g o i n g  theme w i t h t h i s person.  When one  -98c o n s i d e r s the e x p e r i e n c e , r e l a t e d by m a n y t r a n s s e x u a l s , o f f e e l i n g as i f t h e y are b o r n i n t o the w r o n g  b o d y , this theme has i n t u i t i v e v a l i d i t y .  Pre-operatively,  the  t r a n s s e x u a l person not o n l y feels d i f f e r e n t a n d i s o l a t e d f r o m o t h e r s , but also feels incongruent which  w i t h , a n d i n a f a s h i o n isolated f r o m , his or her o w n b o d y .  attempts  to a s c e r t a i n  if  this sense o f  isolation  is t r u l y  Research  common  in  the  t r a n s s e x u a l p o p u l a t i o n (both at the i n t e r p e r s o n a l a n d i n t r a p s y c h i c levels) a n d i f so, then i n w h a t w a y s it m a y be d e c r e a s e d , seems an area o f p a r a m o u n t i m p o r t a n c e to c o u n s e l l o r s d e a l i n g w i t h this these people.  - 99 -  REFERENCES A b r a m o w i t z , S. I. 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(1985) The critical incident technique: An innovative qualitiative research method. U n p u b l i s h e d m a n u s c r i p t . Y a r d l e y , K . M . (1976). T r a i n i n g o f f e m i n i n e s k i l l s i n a m a l e t r a n s s e x u a l : o p e r a t i v e p r o c e d u r e . British Journal of Medical Psychology. 49(A), 392-339. Y i n , R. K . (1984). Publications  a pre-  Case study research design and methods. B e v e r l y H i l l s , C A . : Sage  - 104 -  APPENDIX A Letters of Introduction  - 107 -  APPENDIX B Consent Forms  - 108 -  SUBJECT'S CONSENT F O R M  I agree to participate in a research project, investigating post operative transsexualism. I understand that participation in this study is voluntary and that I am free to withdraw at any time or refuse to answer any question. I understand that I will be interviewed as well as be required to complete a series of three questionnaires. This process will take a maximum of twenty-one hours, spread over five to seven interviews. I do this with the understanding that the information will be kept confidential, used for research purposes only, and destroyed at the end of its usefulness.  - 109 -  PARTICIPANT'S CONSENT  FORM  I agree to p a r t i c i p a t e i n a research project on post o p e r a t i v e t r a n s s e x u a l i s m . I u n d e r s t a n d that p a r t i c i p a t i o n i n this s t u d y is v o l u n t a r y a n d that I a m f r e e to w i t h d r a w at a n y t i m e , or r e f u s e to a n s w e r a n y q u e s t i o n . I understand that I w i l l be i n t e r v i e w e d a n d that t h i s process w i l l take a p p r o x i m a t e l y two hours o f m y t i m e . I do this w i t h the u n d e r s t a n d i n g that the i n f o r m a t i o n w i l l be kept c o n f i d e n t i a l , used f o r research purposes o n l y , a n d w i l l be d e s t r o y e d at the end o f its usefulness.  - 110 -  APPENDIX C A Detailed Interview Guide  - Ill -  A Detailed Interview Guide. Interview #2 with the Case Subject Time focus: From early understanding of transsexualism to the time of surgery. 1.  Please focus on when you first heard about transsexual people. A) You saw Christine Jorgenson on T.V. How old were you? B) What effect did this have on you? Did it alter your thoughts or your feelings or your behavior in any way? C) Did anything happen as a direct result of this?  2.  When did you decide that you might be a transsexual? A) Can you remember anything which helped to bring this about? B) What were the effects of this realization? Did it change the way you thought, behaved or felt? C) Was it a gradual or sudden realization?  3.  You told me, that beginning in Grade 9, you began seeing the school psychologist. A) How did this come about? What triggered it? B) Who's decision was it that you begin counselling? C) What did you and the psychologist talk about? D) Could you tell me about the effect (if any) of these sessions on you? On the people around you?  - 112 When did you decide to inquire about sex-reassignment? A) Having made this decision what did you then do? B) Do you think that making the decision had any noticeable effects on how you behaved? C) Was there anything(s) that helped you in making the decision? Delayed it? In terms of your awakening realization of transsexual feelings . . . A) Whom did you tell first, second, third, etc.? B) What did you tell them? Did you say the same information to each person? C) What were their reactions? D) Can you remember a specific incident(s) that made you feel that you were doing the right thing? The wrong thing? What was your first step i starting the process? A) Did people take you seriously? Who? B) What were their reactions?  What did they say?  C) Did people try and talk you out of it? What did they say? D) Tell me your fondest memories from this period. E) Tell me your worst memories from this period. What prompted you to change your name? A) Did this have an effect on you? Did it have an effect on others around you? B) What were the reactions of people around you? Does any one person's reaction stand out?  - 113 8  Think back to at age 21, when you began to live the majority of your life as a woman. A) As you began to present yourself to the world as a woman, how were life different? Can you give me some examples of this, which seem important? B) Were there any incidents/events, which strike you as particularly helpful/hurtful during this time?  9.  Think back to 1971, you were fired after having disclosed your boss that you were cross-living. A) What did you do think about this? B) How did you feel in the time after it happened? C) What did you do after this happened? D) Did this change or influence your behavior as a consequence of this happening?  10.  You told me in our first interview, that at age 22 after one your of cross-living, you were tired and ready to give up. Please think back to that time. A) Can you remember a specific day or time when you felt like giving up? Tell me about that. B) Can you remember when you decided not to give up? C) Do you know what made you change your mind?  11.  Did you ever feel like you were making the wrong decision? A) Did something happen to make you feel this way? B) What happened to keep you from reverting back to life as a man? C) Was there any time where you did revert to living as a man?  - 114 -  Were you going to school or working during this time? A) Was this an added stress, or did it help? In what way? B) Did people at school/work know that you were going through this process? If so, what were their reactions? Tell me about how you made the initial disclosure about wanting SRS, to Dr. Slazik. A) What was his reaction? B) What did he do? C) Was he helpful? Not helpful? D) Did this have an effect on you? Can you tell me that? How were you emotionally during this time? A) Were you ever depressed? suicidal? happy? B) Who do you remember as being emotionally supportive? What did they do to be supportive? C) Who was nonsupportive, or perhaps destructive? What did they do? D) Can you give further examples of events/incidents which were helpful? What was your relationship with your family like during this period? A) Did it evolve or change as the time of surgery approached? B) What incidents stand out for you?  - 115 -  Tell me about your friendships during this time? A) Are there friends which seem important during this period? What did they do to make them special for you? What makes them seem important? Tell me about going to the Clarke Institute. A) How did you contact them? B) Whom did you see first? C) Did you feel that you were treated fairly? D) What incidents stand out as being helpful to you? E) Were there incidents which you feel were hindering in any way?  APPENDIX D The 'General' Interview Guides.  -117-  I n t e r v i e w #1 w i t h the Case Subject ( D e m o g r a p h i c  Information)  Introduction: "I  would  like  to  begin  these  interviews  by  asking  you  some  basic  i n f o r m a t i o n a b o u t y o u r l i f e f r o m b i r t h t h r o u g h to the present.  T h i s w i l l g i v e me a  basic  will  framework  to  better  understand  the  information  we  discuss in  the  coming interviews." Q u e s t i o n s a n d T o p i c s to be c o v e r e d : 1. F a m i l y C o n s t e l l a t i o n ( G e n o g r a m ) 2.  Place of b i r t h  3.  R e s i d e n c e s l i v e d i n to the present  4.  E d u c a t i o n a l h i s t o r y (schools, trade s c h o o l , etc.)  5.  Employment history  6. M e d i c a l h i s t o r y 7. T r a n s s e x u a l h i s t o r y - f i r s t thoughts of f e e l i n g as a w o m a n f i r s t h e a r i n g about t r a n s s e x u a l i s m a n d sexreassignment - f i r s t e x p e r i e n c e cross d r e s s i n g - p o i n t of l i v i n g as a w o m a n The  purpose  of  this  initial  interview  f r a m e w o r k a n d to g a t h e r basic i n f o r m a t i o n . life  overview  interviews did.  rather  than  an i n t e n s i v e  was  to  establish a  chronological  It a t t e m p t e d to a c c o m p l i s h a g e n e r a l  study  of  events  such  as the  following  - 118 -  I n t e r v i e w w i t h Subject's m o t h e r a n d f a t h e r (to be i n t e r v i e w e d s e p a r a t e l y ) 1. Please t h i n k b a c k to the t i m e w h e n T e r r y was a c h i l d , say b e f o r e the age o f ten.  D i d she have m a n y f r i e n d s ?  Were they boys? G i r l s ? B o t h ? 2.  A r e there a n y issues or p r o b l e m s r e l a t i n g to s o c i a l l i f e w h i c h s t a n d out f r o m this time?  3.  H o w d i d T e r r y do at school? (e.g. a c a d e m i c a l l y , s o c i a l l y , g e t t i n g a l o n g w i t h her teachers).  4.  A r e there a n y events f r o m these f i r s t f e w s c h o o l years w h i c h s t a n d out f o r you?  5.  O n c e T e r r y r e a c h her teenage years d i d y o u ever suspect that s o m e t h i n g was not r i g h t or was t r o u b l i n g her?  6.  Was it T e r r y w h o f i r s t t o l d y o u about her suspected transsexualism?  When d i d this happen?  go a b o u t t e l l i n g y o u ?  H o w d i d she  What was y o u r r e a c t i o n ?  7. A f t e r the i n i t i a l d i s c l o s u r e , d i d you c o n t i n u e to discuss it?  What were those d i s c u s s i o n s l i k e ?  What  stands out ( i f a n y t h i n g ) f r o m those discussions? 8.  What was the r e a c t i o n o f y o u r spouse? Other relatives?  9.  Y o u r son?  Friends?  Was T e r r y a w a r e o f these reactions?  10. R e m e m b e r b a c k to the f i r s t time you saw T e r r y dressed as a w o m a n . d i d you think?  What was y o u r r e a c t i o n ?  H o w d i d y o u behave?  What  -11911. What was y o u r r e l a t i o n s h i p l i k e d u r i n g this p e r i o d ? 12. What was the r e a c t i o n of y o u r spouse to this c h a n g e Ln T e r r y ?  What was the r e a c t i o n of y o u r son?  relatives?  F a m i l y friends?  Other  13. D i d people discuss the s i t u a t i o n o p e n l y ? 14. Was T e r r y a w a r e o f the r e a c t i o n s of people (i.e. f a m i l y , f r i e n d s ) to her d u r i n g this p e r i o d ? 15. What is y o u r c u r r e n t r e l a t i o n s h i p w i t h T e r r y l i k e ? 16. D o y o u f e e l that T e r r y is d o i n g w e l l t o d a y ? 17. D o y o u f e e l that T e r r y s t i l l faces d i f f i c u l t i e s as a result o f b e i n g a t r a n s s e x u a l ?  C o u l d you give  some e x a m p l e s ? 18. D o y o u t h i n k that T e r r y is better o f f f o r the sexr e a s s i g n m e n t process?  Why?  19. D o y o u t h i n k of T e r r y as a w o m a n ?  I n t e r v i e w w i t h the Case Subject's  brother  1. T h i n k b a c k to w h e n T e r r y was a s m a l l c h i l d , say b e f o r e the age o f ten. Boys? 2.  D i d she have m a n y f r i e n d s ?  Girls?  A r e there a n y p a r t i c u l a r s o c i a l p r o b l e m s or successes w h i c h s t a n d out f o r y o u r f r o m this time?  3.  Were y o u a n d she close d u r i n g this time?  If so,  w h a t k i n d s of a c t i v i t i e s d i d you do together? 4.  R e m e m b e r T e r r y i n e l e m e n t a r y school.  H o w d i d she  get a l o n g ? (e.g. a c a d e m i c a l l y , w i t h teachers, etc.). H o w a b o u t i n h i g h school?  - 120 5. Are there things from the school age period which stand out for you? 6. When Terry was a teenager (or before) did you ever think that something was not right, or perhaps was bothering her? 7. How did you find out that Terry was transsexual? Did you understand what that meant? 8. What was your reaction to this information? 9. Did you say anything to Terry? To your mother? Your father? 10. What was your mom's reaction?  Your dad's reaction?  Other friends or relatives of the family? 11. Was Terry aware of these reactions? 12. When did you first see Terry as a woman? 13. What was your reaction?  What did you say? Think?  Feel? 14. What was your relationship like with Terry during this period when she first began to live as a woman? Was it different than before? How? 15. What about her relationships with other family members? Can you remember specific incidents? 16. Did you and your family talk about what was happening with Terry at this time? Can you tell me about those conversations? 17. What is your current relationship with Terry like? How does it compare with your relationship during other periods in your lives?  - 121 18. D o y o u t h i n k that T e r r y is d o i n g w e l l ?  In w h a t way(s)?  19. W h a t / w h o has h e l p e d her most? 20. W h a t / w h o has h i n d e r e d or h u r t her? 21. D o y o u t h i n k that T e r r y is better o f f f o r the sexreassignment surgery?  Why?  22. D o y o u t h i n k of T e r r y as a w o m a n ?  I n t e r v i e w #3 w i t h the Case Subject.  T h e t o p i c is ' f a m i l y l i f e ' a n d the t i m e f o c u s ,  is f r o m the e a r l i e s t r e c o l l e c t i o n s , to the present. 1. T h i n k b a c k to the t i m e b e f o r e you entered s c h o o l . Were those h a p p y times? C a n you tell me some of the events or m e m o r i e s w h i c h make y o u r e m e m b e r t h e m the w a y y o u do? 2.  What was y o u r r e l a t i o n s h i p w i t h y o u r m o t h e r l i k e d u r i n g that t i m e ?  3.  With your father?  What w a s y o u r r e l a t i o n s h i p w i t h y o u r b r o t h e r l i k e ? y o u a n d he close?  4.  Were  In w h a t w a y ?  D i d y o u do t h i n g s as a f a m i l y ?  C a n you g i v e some  examples? 5.  What stands out f o r you f r o m this p e r i o d ?  What seems  important? 6.  Y o u ' v e t o l d me that you were t a k e n to see a d o c t o r because y o u w o u l d n ' t p l a y w i t h "boy's toys". o l d w e r e y o u w h e n this o c c u r r e d ?  How  D o y o u r e m e m b e r it?  If so, w h a t d i d you u n d e r s t a n d about i t , at the t i m e ? 7. D i d y o u f e e l l o v e d a n d a p p r o v e d o f by y o u r m o t h e r d u r i n g this p e r i o d o f time?  By your father?  - 122 8.  A s y o u g r e w o l d e r , d i d these f e e l i n g s ( r e l a t i n g to l o v e a n d a p p r o v a l ) r e m a i n stable or d i d they change i n some way?  9.  If so, c a n y o u e x p l a i n how they c h a n g e d ?  D i d y o u ever f e e l pressure to c o n f o r m i n a n y w a y ? (For example:  as a m a l e , s o c i a l l y , a c a d e m i c a l l y , i n  c h o o s i n g a p r o f e s s i o n , etc.). 10. What was h o m e l i f e l i k e w h e n y o u were a teenager? 11. What events s t a n d out f o r y o u f r o m this t i m e ? 12. W h e n y o u d i s c l o s e d that y o u t h o u g h t you were a transsexual, what happened?  What were the r e a c t i o n s  o f the people y o u d i s c l o s e d to?  Whom d i d you tell  f i r s t , s e c o n d , etc.. 13. When d i d y o u leave home?  What were y o u r reasons  f o r l e a v i n g home a n d y o u r f e e l i n g s s u r r o u n d i n g the move? 14. D i d y o u c o n t i n u e to see y o u r parents? relationship different?  H o w was y o u r  H o w was it the same?  15. D i d y o u f e e l more or less accepted by y o u r parents a f t e r y o u m o v e d out, or d i d y o u r f e e l i n g s o f a c c e p t a n c e r e m a i n the same? What were the type o f t h i n g s y o u r p a r e n t s d i d to m a k e you f e e l this w a y ? 16. H a v i n g d i s c l o s e d y o u r t r a n s s e x u a l i s m to y o u r parents d i d y o u ever f e e l rejected as a result o f it?  D i d you  ever regret t e l l i n g them? 17. D i d they try a n d l e a r n about t r a n s s e x u a l i s m a n d a b o u t the process you were g o i n g t h r o u g h ?  - 123 18. When did they begin to refer to you as their daughter?  What was that like? Do you remember the  first time they did that? 19. Do you feel accepted as a woman, and as an individual, by your parents currently?  Interview #4 with Case Subject.  The topic is pre- and post operative romance,  sexual relationships and sexual functioning. 1. Did you date as a teenager? Were your dates, with females, or males, or both? 2. Think back to those times. Was dating an enjoyable experience?  Do any of them standout?  Tell me about  some of your dates? 3. Tell me about some of your early sexual experiences. Who were they with? Were they enjoyable? 4. What do you consider your first serious relationship? Tell me about what that relationship was like? 5. When you began to cross-dress frequently, did you date as a woman? Can you remember some of these experiences? 6. In dating situations, have your partners been aware that you have had sex-reassignment? 7. What have been some of their reactions upon finding out? 8. Your brother told me that you had told him about an experience once, where someone became violent with you. Can you tell me about that?  - 124 9. Have you had relationships which terminated after your partner found out the you were transsexual? 10. Do you consider your transsexualism an impediment or an advantage.  Please elaborate and explain in what ways.  11. Do you think that men respond to you as they would respond to a woman who has not had sex-reassignment? 12. What would be the ideal relationship for you? 13. Do you feel that this is realistic and achievable? Please explain. 14. In what ways is your current relationship similar to past relationships? In what ways is it different? 15. What are this relationships strengths?  What are its  weaknesses? 16. Are you happy with the state of your romantic life? What pleases you about it? What would you change? 17. Sexually, how do you compare your satisfaction now, with when you were a man? 18. Are you orgasmic?  Is the sensation of orgasm  different, than when you were a man? If so, in what way? 19. Are you satisfied with the surgical construction of your genitals?  Interview #5  Have you ever been dissatisfied?  with Case Subject. The topic is 'friendships' (both pre- and post  operatively). 1. As a teenager, did you have close friends? Did you have acquaintances? did you do with them?  What kinds of activities  - 125 2.  D i d y o u o f t e n f e e l l o n e l y or i s o l a t e d ? C a n y o u r e m e m b e r s p e c i f i c times w h e n y o u f e l t l i k e l o n e l y and/or isolated?  3.  Please t e l l me about these.  Who was the f i r s t f r i e n d y o u t o l d about y o u r f e e l i n g s o f b e i n g the w r o n g gender? their reaction?  What was  D i d it e n c o u r a g e or d i s c o u r a g e y o u  f r o m t e l l i n g others?  D i d it change y o u r r e l a t i o n s h i p  w i t h that person? 4.  A s y o u began to l i v e as a w o m a n , d i d y o u h a v e close friends?  5. T e l l me a b o u t these f r i e n d s . Supportive? 6.  Were they a c c e p t i n g ?  Rejecting?  D i d you have f r i e n d s w h o were also t r a n s s e x u a l ? C a n y o u t e l l me about those r e l a t i o n s h i p s ?  7.  D i d y o u have f r i e n d s w h o stayed constant  throughout  the process of s e x - r e a s s i g n m e n t ? 8.  A s y o u were g o i n g t h r o u g h that process, d i d y o u f e e l that y o u c o u l d c o n f i d e i n y o u r f r i e n d s ? u n d e r s t o o d by t h e m ?  9.  D i d you feel  What made y o u f e e l that w a y ?  D o y o u f e e l that y o u c a n c o n f i d e i n y o u r present friends.  D o you f e e l that they are 'deep f r i e n d s h i p s ' ?  C a n y o u t e l l me about these r e l a t i o n s h i p s ? 10. Is w h a t y o u w a n t f r o m f r i e n d s h i p s n o w , d i f f e r e n t t h a n before SRS?  In w h a t ways?  A r e you g e t t i n g w h a t you  want f r o m your current friendships. i n w h i c h you are d i s s a t i s f i e d ?  Is there a n y area  - 126 11. Do you feel that you can count on your friends when you need them? 12. Do you feel accepted by your friends?  What do they do  to make you feel accepted or to make you feel not accepted? 13. Do you have a feeling of 'belonging' with your friends, or do you feel somewhat apart? Explain. 14. Do you ever feel 'judged' by your friends?  In what way,  and around what issues? 15. Do you do activities or see your friends on a regular basis? Tell me about some of these activities? 16. Do you discuss thoughts/feelings/problems etc., related to being transsexual, with your friends? 17. What defines your closest friends, as such? What is it that sets them apart from people less close to you?  Interview with Subject's friends and peer group. 1. How long have you known Terry? 2. Tell me about how you met Terry? 3. Did you know that Terry was transsexual when you met her? How did you find out? What did you understand this to mean? 4. Tell me about your relationship with Terry. Do you feel that you are 'close' to her? In what way? Do you see her often? Do you see her as much now as you did in the past? More? What kinds of activities do the two of you do together?  - 127 5. Does Terry have other close friends? Do you know those people? 6. Does Terry seem lonely to you? What makes you think that she is (isn't) lonely? 7. Do you ever talk about issues relating to transsexualism? If so, could you tell me about some of these discussions? 8. Did you know Terry as a man? Do you think of her as a woman now? 9. Does Terry's transsexualism affect your relationship? If so, can you think of incidents or examples which have happened which seem to you to show your relationship, being affected by it? 10. Do you see Terry as basically happy? Sad?  Both?  Please explain. 11. What kinds of problems do you think that Terry faces being a post operative transsexual? Could you give examples of these problems, and if possible how you have seen Terry deal with them (or not deal with them)? 12. Do you have to deal with problems that arise as a result of being a friend to Terry? Explain. 13. Have you ever seen instances where Terry was ridiculed, singled out, or in some way isolated for being a transsexual? 14. Is it common knowledge among her friends and acquaintances which you know, that Terry is a transsexual?  - 128 15. Having known Terry pre-operatively, have you seen her change and grow into the female role post operatively (note: only to be asked of people who knew her preoperatively) 16. Do you ever see things in Terry that remind you that she was once a man? 17. Have you seen incidents or people doing things which seem to help Terry get along, or perhaps which, have hurt her or stood in her way? Explain.  Interview #6 with the Case Subject. The topic, is post operative life experience. 1. Think back to being in the hospital, waking up from the anesthetic.  Do you recall any of your thoughts and  feelings? Can you tell me about those? 2. In those first days after surgery, were you pleased with the results? 3. After leaving the hospital, do you remember consciously 'working' at being feminine? 4. Were you worried about 'passing'? 5. Were there times when you felt stared at, singled out, etc.? Can you give some examples of these times? 6. Did you ever try and hide your past as a man? When? Why? 7. Did you ever try and shock people with your past? Can you remember specific instances?  - 129 8. Do you feel that there was a point of 'stabilizing' in the new role? When was it? What makes it a point of stabilizing? 9. Are you pleased with your physical appearance now? 10. Do you ever feel 'read' as a transsexual now? How does that make you feel? Can you give some examples of when that happened which stand out for you? 11. Do you still think at times, that you have to 'work' or struggle to get along, in ways that people born into their genders do not? 12. Do you feel that you 'blend in' or do you sometimes feel that you stand out? Can you give examples of either, or both? 13. Do you feel that what you've gone through has been worth it? Why? Is it a success? 14. If a nineteen year old male came to you now, and said that he wanted to begin the process of sex-reassignment, what advice would you give him? 15. Looking back, what could you have done differently to make it easier? 16. If you could go back in time, who would you 'hug' and who would you 'tell off? Explain.  Interview #7 with the Case Subject This final interview with the case subject, had no guide formulated in advance; instead, it consisted of a series of questions which attempted to clarify some of  - 130 -  information elicited in the previous interviews.  It also included an informal  discussion of the experience and impact of the interview process itself.  - 131 -  APPENDIX E A Thematic Classification  - 132 -  A Thematic Classification Unlike the initial classification of the critical incidents, this classification is not meant to consist of mutually exclusive categories, nor is it meant to be seen as the primary classification scheme for the project. attempt  It is presented here in an  to clarify, for the interested reader, the relationship which the case  investigator has drawn between specific 'incidents' and what he sees as underlying themes.  The  investigator  does  not  claim that  this  is  the  only  thematic  interpretation and resulting classification scheme possible, nor even perhaps the definitive one; it is however, one which has a validity for the case investigator in his experience both as researcher and as clinician. Incidents Relating to the Theme of Acceptance (8) versus Rejection (2): #3-Change of surname (R) #5-Mother discovers that subject has not attended air cadets (A) #6-Mother discovers of letters regarding SRS (A) #7-Telling father and brother about efforts to attain SRS (A) #14-J3eing calmed by surgeon (A) #13-Surgeon supports SRS (A) #19-Fired from job in Toronto (R) #20-Former employer asks Subject to return to Regina (A) #24-Family friend speaks to her son and his friends 'about Henry' (A) #26-Joins West End Players (A) Incidents Relating to the Theme of Competency (4) versus Incompetency (1): #15-Subject begins to charge for hairstyling (C) #16-J3uys first salon in Oxbow (C) #18-Wins provincial hair styling competition (C) #21-Buys salon in Regina (C) #23-Going to Air Cadets (I) Incidents Relating to the theme of Isolation (3) versus Belonging (2): #1-Suicide attempt at age 15 (Is) #4-Suicide attempt age 31 (Is) #22-Regina salon burns down (Is) #27-Moving in with D. D. (B) #28-Sees Christine Jorgenson on T.V. (B)  - 133 Incidents Involving Themes of both Competency versus incompetency (7) and Acceptance versus Rejection (1): #2_-First cross-dressing in public (C,A) #9-Ridiculed by Grade 9 teacher (I,R) #10-Attending trade school (C,A) #11-Psychiatrist makes transsexual diagnosis (C,A) #12-First response from John Hopkins (C,A) #17-Organizes community hair and fashion show (C,A) #29-Man on plane comments on subject's attractiveness C,A) #30-Going to first bar cross-dressed in Toronto (C,A) Incidents Involving Themes of both Acceptance versus Rejection (1) and Isolation versus Belonging (1): #8-First post SRS Christmas card (A,B) #25-Moves to Vancouver to live with A. (R,Is)  

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