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The male to female transsexual : a case study 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 FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF ARTS i n 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 EDUCATION T H E DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept this Thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1988 ©Daniel Norman Blanchard, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) - i i - A B S T R A C T T h i s study was under taken to examine the deve lopment and ongoing ad justment of a m a l e - t o - f e m a l e t ranssexual . 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 w i th the case subject , selected f r i e n d s and f a m i l y members , the research at tempted to uncover i n c i d e n t s w h i c h were c r i t i c a l in this person's post operat i ve psycho log ica l and soc ia l ad justment . The in te rv iews were conducted in accordance w i t h gu ide l ines set d o w n by F l a n a g a n (1954). The inc idents were c l a s s i f i e d in accordance w i t h the eco-systemic f r a m e w o r k put f o r t h by Conger (1981). Th i s theoret ica l f r a m e w o r k emphas ized the context w i t h i n w h i c h the inc idents occur red . P s y c h o l o g i c a l and soc ia l adjustment were assessed by three s t a n d a r d i z e d inst ruments : 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 Inventory ( H a t h a w a y & M c K i n l c y , 1967); The Soc ia l Support Ques t ionna i re (Sarason, L c v i n c & Basham, 1983) ; and The F a m i l y Assessment Measure (Sk inner , 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 in te rv iews a total of 30 " c r i t i c a l inc idents" were revealed . O f the 30 inc idents , 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 ana lys is . T h i s result underscored the impor tance of va r ious c o m m u n i t y level systems or groups, at both the pre- and post operat i ve stages. Once c l a s s i f i e d , the inc idents were ra ted , by both the case subject and case inves t iga to r , in terms of re la t i ve impor tance to the i n d i v i d u a l ' s post operat i ve ad justment . These inc idents were then discussed in terms of three p r i m a r y themes: acceptance versus re ject ion , competency versus incompetency , and i so la t ion versus be long ing . In a d d i t i o n to the c r i t i c a l i nc idents , a series of ongo ing s i t u a t i o n a l i n f l u e n c e s were revealed d u r i n g the i n t e r v i e w process. These i n f l u e n c e s were also c l a s s i f i e d in terms of Conger 's (1981) eco -systemic c l a s s i f i c a t i o n system. The s i t u a t i o n a l i n f l u e n c e s were discussed in terms of two p r i m a r y themes: personal style and in te rpersona l re lat ionsh ips . - I l l - T A B L E OF C O N T E N T S A B S T R A C T i i L I S T O F T A B L E S i v L I S T O F F I G U R E S v L I S T O F A P P E N D I C E S vi A C K N O W L E D E M E N T S v i i CHAPTER I I N T R O D U C T I O N 1 N a t u r e of the P rob lem 2 Purpose of the Study 3 Eco log i ca l -Sys tems M o d e l 5 Research Quest ions 7 CHAPTER II R E V I E W O F T H E L I T E R A T U R E 9 Research on C l a s s i f i c a t i o n and D iagnos is 9 Research on E t i o l o g y 17 Research on T reatment Outcome 20 CHAPTER III M E T H O D O L O G Y 32 The Case S tudy 32 T h e Case Subject 34 T h e Case Study Invest igator 36 T h e S e m i - S t r u c t u r e d In terv iew 37 T h e C r i t i c a l Inc ident T e c h n i q u e 45 The C r i t i c a l Inc ident Scale 46 S t a n d a r d i z e d Instruments 47 M i n n e s o t a M u l t i p h a s i c Persona l i t y Inventory 48 The F a m i l y Assessment Measure 50 Soc ia l Support Ques t ionna i re 52 CHAPTER IV R E S U L T S 56 I n t r o d u c t i o n 56 M M P I P r o f i l e Interpretat ions 56 F a m i l y Assessment Measure 61 The Soc ia l Support Ques t ionna i re " 74 The C r i t i c a l Inc idents 75 S i t u a t i o n a l In f luences 77 CHAPTER V S U M M A R Y A N D D I S C U S S I O N 80 T h e Test Resu l ts 81 T h e C r i t i c a l Inc idents 84 T h e S i t u a t i o n a l In f luences 88 U n d e r l y i n g Themes 90 Research Quest ions : Conc lus ions 91 T h e Resu l ts W i t h i n The Contex t O f Other Research 93 L i m i t a t i o n s of the Study 96 I m p l i c a t i o n s and Suggestions For F u t u r e Research 97 REFERENCES 99 - iv - LIST OF T A B L E S 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 Inc idents 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 In f luences 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 Invest igator 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 Inc idents LIST OF FIGURES FIGURE 3.1 Schedu le of Data C o l l e c t i o n 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 and her Mother : 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 Case Subject and her Brother 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 and her Father FIGURE 4.8 The Se l f R a t i n g P r o f i l e - VI - LIST OF APPENDICES 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 - V l l - A C K N O W L E D G E M E N T S There are a number of people who have p layed s i g n i f i c a n t roles in the p r o d u c t i o n of this thesis and 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. Dr . John F r i e s e n , the cha i rperson of my thesis commit tee , has been a source of much encouragement and enthus iasm f r o m the i n c e p t i o n of this project to its •complet ion . D r . R o b e r t C o n r y gu ided me in the execut ion of a methodology w h i c h at t imes I f o u n d c o n f u s i n g and unclear . H i s comments were as i n s i g h t f u l as his humor en joyable . I w o u l d also l ike to acknowledge the t h i r d member of my commit tee , 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 helped to focus my thoughts in this area. I want to thank my parents, C l a r a and D o u g , whose u n c o n d i t i o n a l be l ie f in my a b i l i t i e s has a lways been a source of support , and sometimes of refuge. Wi thout my par tner T o m , who p r o v i d e d e v e r y t h i n g f r o m 'tea and s y m p a t h y ' to expert computer a d v i c e , I'm not sure that I wou ld 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 want to acknowledge T e r r y , my case subject and co- researcher. He r generos i ty , openness and pat ience w i t h my endless quest ions made this project possible. T h r o u g h o u t the course of our conversat ions I came more and 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 own history . She w i l l a lways have my grat i tude and a d m i r a t i o n . - 1 - C H A P T E R 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 in a b i o l o g i c a l l y n o r m a l person of being a member o f the opposite sex. T h i s be l ie f is sometimes a c c o m p a n i e d by a request for su rg i ca l a n d e n d o c r i n o l o g i c a l procedures that change a n a t o m i c a l appearance to that of the opposite sex (Stol ler , 1968). The D S M III (1980) de f ines the phenomenon as "a heterogeneous d isorder of gender i d e n t i t y (the sense of k n o w i n g to w h i c h sex one belongs)." T h e p r i m a r y features are "a persistent sense of d i s c o m f o r t and inappropr ia tencss about one's anatomic sex and a persistent wish to be r i d of one's genita ls and to l i ve as a member 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 and d iagnos is has been one of ongo ing debate: a debate w h i c h cont inues today. P a r a l l e l w i t h e f f o r t s to d iagnose, there has been a concerted attempt to d iscover the cause(s) of this seeming ly aber rant percept ion of gender i d e n t i t y . The results of this stream of research remain e q u i v o c a l . Some wr i te rs arc now suggest ing that the m a j o r i t y of the ev idence points to a 'social l e a r n i n g ' basis fo r the deve lopment of the syndrome ( H o u l t , 1983/84), w h i l e others take a more i n t e r a c t i v e stance between b i o l o g i c a l and p s y c h o l o g i c a l theories of et io logy ( H o e n i g , 1985). E t h i c a l , legal and m e d i c a l i m p l i c a t i o n s of sex- reassignment have been argued as w e l l . Resu l ts of outcome studies now suggest that fo r an a p p r o p r i a t e l y d iagnosed group, su rg i ca l sex - reass ignment docs appear as the best o p t i o n ( H u n t and 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 many of these issues are common to the study of both male and female t ranssexuals , this study focuses p r i m a r i l y on the phenomenon of the male (i.e. b i o l o g i c a l l y male) t ranssexual . A n e x p l o r a t o r y , s ing le case design was selected to study an i n d i v i d u a l m a l c - t o - f e m a l e post operat i ve t ranssexual who has l i ved in - 2 - the c o m m u n i t y fo r a s i g n i f i c a n t length of t ime ( four teen years) in an apparent l y successfu l manner . The analys is attempts to app ly an eco log ica l systems c l a s s i f i c a t i o n to the ' c r i t i c a l inc idents ' g leaned f r o m i n t e r v i e w s w i t h the case subject and s i g n i f i c a n t others in her l i f e . T h e purpose of this ana lys is is to i l l u m i n a t e the range of in f luences w h i c h have a f f e c t e d her post operat ive ad justment and to increase the e m p i r i c a l data base on m a l c - t o - f e m a l e post operat i ve t ranssexuals . Nature of the problem E x a m p l e s of what we now term as t ranssexua l i sm have been recorded throughout h is tory (Steiner, 1981), a l though s c i e n t i f i c study of the phenomenon has been p r i m a r i l y l i m i t e d to the last fo r t y years. The term was co ined by C a l d w e l l in 1947. In the 1950's, the case of C h r i s t i n e Jorgenson was reported w i d e l y in the popu la r press ( B a l l , 1981). For the f i rs t t ime, the c o n d i t i o n of t ranssexua l i sm and the i n t e r v e n t i o n of sex - reassignment surgery began to enter the p u b l i c consciousness. A c c o m p a n y i n g this increase in p u b l i c awareness was a c o r r e s p o n d i n g increase in demand fo r the surgery ( B a l l , 1981). A s a consequence, the p s y c h i a t r i c c o m m u n i t y was faced w i t h an inc reas ing l y heterogeneous p o p u l a t i o n request ing sex - reassignment ( B a l l , 1981). Due to this heterogeneity in the pat ient/c l ien t p o p u l a t i o n , issues of d iagnos is and 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 complex . Research in to this area was f r a u g h t w i t h d isagreement . T h o u g h a var ie ty of schemas were i n t r o d u c e d , the issue remains content ious to this day. A s s c i e n t i f i c interest inc reased , e t i o l o g i c a l issues became a p r i m a r y focus of study. A g a i n , results were c o n f l i c t i n g ; some authors suggested that the majo r i t y of the ev idence supports a ' soc ia l l e a r n i n g ' model of et io logy ( H o u l t , 1983/84) wh i le other authors suppor ted the v iew that psycho log ica l fac tors may come into e f fec t - 3 - on ly i f a b i o l o g i c a l p red ispos i t ion is f i r s t in place (Hoen ig , 1985; M o n e y , Hampson and H a m p s o n , 1957). Studies of t reatment outcome suggest that sex - rcass ignmcnt surgery is the p re fe r red mode of t reatment in a select group of a p p r o p r i a t e l y d iagnosed i n d i v i d u a l s ( H u n t and H a m p s o n , 1980). Research also ind icates that surgery does not p rec lude the use of psychotherapy in d e a l i n g w i t h both pre - and post operat ive issues ( L o t h s t e i n , 1983). In a d d i t i o n it appears that in the m a j o r i t y of cases, post operat i ve ad justment is s i g n i f i c a n t l y a f f e c t e d (pos i t i ve ly ) by psychotherapy in c o n j u n c t i o n w i t h m e d i c a l t reatment ( Lo ths te in , 1980). Some authors have recent ly suggested, however , that the f requency 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 a p p r o p r i a t e ' t ranssexuals has been too great and that in ce r ta in cases, n o n - s u r g i c a l in te rvent ions (i.e. psychotherapy ) wou ld be more successfu l ( Lo ths te in , 1983). Purpose of the S tudy T h o u g h interest as wel l as d isagreement in areas of e t io logy , t reatment , and c l a s s i f i c a t i o n is ongo ing w i t h i n 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 faced w i t h i n d i v i d u a l s d i s p l a y i n g symptoms w h i c h meet var ious c r i t e r i a for d iagnosis as t ranssexua l . In a d d i t i o n , m e d i c a l i n te rvent ion in the f o r m of sex - rcass ignmcnt surgery (SRS) is p e r f o r m e d in var ious count r ies , i n c l u d i n g C a n a d a . It appears that we are not in a pos i t ion where p rc -opera t i ve issues may be s tud ied exhaus t i ve l y before b e g i n n i n g the study of post operat ive ones. A c c e p t i n g that at present psychotherapeut ic i n t e r v e n t i o n is usefu l in c o n j u n c t i o n w i t h S R S fo r the most pos i t i ve post operat i ve prognosis , the goal of this s tudy was to exp lore the f o r m this i n t e r v e n t i o n (i.e. psychotherapy ) might o p t i m a l l y take , and the general issues on w h i c h it might focus. T h o u g h d i f f e r e n c e s between i n d i v i d u a l s sure ly ex ist , e m p i r i c a l research in areas such as psych ia t r y , c l i n i c a l psycho logy , and counse l l i ng psychology has p r o v i d e d theory and statements - 4 - of p r i n c i p l e . Such i n f o r m a t i o n guides therapists in the i r w o r k w i t h i n d i v i d u a l s . Statements of p r i n c i p l e and theory appear to have been l a c k i n g fo r the persons descr ibed as t ranssexual . T h e purpose of this study has been to reveal the deve lopment and ongo ing ad justment of an i n d i v i d u a l w i t h i n the context of her l i f e c i rcumstances . T h i s focus d i f f e r s f r o m that of most of the pub l i shed research (e.g. R a n d e l l , 1969; Skapec and M a c k e n z i e , 1981), w h i c h appears la rge ly to have ignored the impact 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 , and legal profess ions , and other 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 and compr ise the context w i t h i n w h i c h l i f e is l i v e d . The except ion to this s i tua t ion arc cer ta in studies c i ted w h i c h focus on the et io logy of the t ranssexual syndrome. B r o n f e n b r e n n e r (1977) proposed an eco log ica l systems model fo r research w h i c h v iews the rec ip roca l in te rac t ion of a series of "nested systems." U s i n g Conger 's (1981) adapta t ion of this model as the basis fo r the ana lys i s of an i n d i v i d u a l case, the present research e x a m i n e d how such 'systems' as the f a m i l y , peer g roup , m e d i c a l and 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 operat ive ad justment of the i n d i v i d u a l . T h i s s tudy docs not p rov ide d e f i n i t i v e answers , it does however en r i ch the e x i s t i n g k n o w l e d g e base in the area of t ranssexua l i sm. Perhaps more i m p o r t a n t l y , by t a k i n g the case study a p p r o a c h , and e x a m i n i n g what factors are perce ived as s i g n i f i c a n t in this person's post operat i ve ad justment , and how they have in teracted to a f f e c t this i n d i v i d u a l , the study prov ides an a l t e r n a t i v e focus to much of the pub l i shed research in this area. T h i s project cont r ibutes to the deve lopment of an e c o l o g i c a l , systemic u n d e r s t a n d i n g of post operat ive t ranssexual ad justment f r o m w h i c h c l i n i c i a n s may d r a w when ca l led upon to intervene w i t h this p o p u l a t i o n . - 5 - The Ecological-Systems Model C e n t r a l to systems theory is the be l ie f that the var ious elements o r parts o f a bounded un i t (i.e. a system) are in terdependent . A s each element acts and reacts, it cannot help but have an e f f e c t , e i ther d i r e c t l y or i n d i r e c t l y , upon other elements w h i c h i n tu rn react and have an e f f e c t on the o r i g i n a l un i t at some later moment i n t ime (Conger , 1981). H i s t o r i c a l l y , systems theorists have d e f i n e d this 'bounded u n i t ' as be ing the f a m i l y (Ha ley , 1963). T h e result of this d e f i n i t i o n was a focus on the ' f a m i l y system' and the var ious subsystems w h i c h compr ise it. B r o n f e n b r e n n e r (1977, 1979) proposed an expans ion of this model for the study of c h i l d deve lopment . E m p h a s i z i n g the not ion of ' r e c i p r o c i t y ' ( i n te rac t ing and 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 iewed a s one o f a series of micro -sys tems 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 . In his descr ip t ions o f the d i f f e r e n t levels of systems, he gave examples w h i c h a p p l i e d to adul ts a s wel l as to c h i l d r e n . T h i s suggests that he v iewed the i n d i v i d u a l as a d y n a m i c system d e v e l o p i n g throughout the l i f e cyc le . C o u p l e d w i t h his not ion of 'eco log ica l t r a n s i t i o n ' (where the i n d i v i d u a l ' s pos i t ion is changed in the e n v i r o n m e n t a s a result of change in role , set t ing , or both [1979, p. 26]), it w o u l d seem that the eco log ica l systems model is an appropr ia te model f o r s t u d y i n g the ent i re l i f e cyc le , and is not l i m i t e d to a study of c h i l d h o o d . Conger (1981), b u i l d i n g on the work of B r o n f e n b r e n n e r proposes his own model fo r b e h a v i o r a l assessment of f a m i l i e s . " 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 concerned w i t h the rec ip roca l i n f luences that i n d i v i d u a l charac te r i s t i cs , f a m i l y d y n a m i c s , and t ransact ions w i t h the outs ide c o m m u n i t y have on one another." (p. 202) T h e focus is on the c reat ion of a f r a m e w o r k w h i c h stresses the in te rac t ion of three p r i m a r y levels of analys is . T h e levels of ana lys is and i l l u s t r a t i v e measures proposed by Conger are s u m m a r i z e d in Tab le 1.1. - 6 - T A B L E 1.1 T H E E C O L O G I C A L S Y S T E M S F R A M E W O R K Level of Analysis Illustrative Measures 1. The individual family member a. Social background (parents) b. Experiences in family of origin c. Mood: depression d. Intellectual functioning e. Excessive, deficient, or inappropriate behavioral characteristics 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 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) 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. 2. The family system 3. The community - 7 - Research Questions What are the s i g n i f i c a n t factors in the post operat ive ad justment of a m a l c - t o - f e m a l e t ranssexual? What are the consequences of these fac to rs , and why arc they seen as s i g n i f i c a n t i n the subject's post operat ive ad justment? 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 , what is the i r order of s i g n i f i c a n c e ? Definitions Transsexual O ' G o u r m a n (1982, p.23) def ines t ranssexua l i sm as " . . . a d i s tu rbance of sexual i d e n t i t y in w h i c h the pat ient 's m o r p h o l o g i c a l sex is i n c o n g r u c n t w i t h p s y c h o l o g i c a l sex. T h e pat ient pers istent ly seeks to l i ve as a member of the other sex." F o r the purpose of this s tudy , the i n d i v i d u a l under inves t iga t ion had exper ienced the process of d iagnos is , sc reen ing , and m e d i c a l i n te rvent ion (sex- reassignment surgery) and had l i ved post opera t i ve l y as a woman for some fourteen years p r io r to the study. Adjustment In this s tudy , 'ad justment ' focused on the i n d i v i d u a l ' s level of both p s y c h o l o g i c a l and soc ia l f u n c t i o n i n g as measured by se l f - repor t inst ruments . A reas assessed i n c l u d e d : - f a m i l y f u n c t i o n i n g , - i n t e r p e r s o n a l re la t ionsh ips and soc ia l support , - se l f image, and - p s y c h o l o g i c a l f u n c t i o n i n g Pre-operative Transsexual A t ranssexual person before sex - reassignment surgery . - 8 - Post Operative Transsexual A t ranssexua l person a f te r sex - reassignment surgery. S i g n i f i c a n t Fac to rs A s i g n i f i c a n t fac to r may be an i n d i v i d u a l event (e.g. d isc losure to the f a m i l y of the subject's desire fo r sex - reassignment surgery) or a s i t u a t i o n or set of c i r cumstances over some discrete per iod of t ime (e.g. economic d i f f i c u l t i e s ) . D a t a were generated by us ing several methods: se l f - repor t ; 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 , f r i e n d s , i n v o l v e d pro fess iona ls ; and data f r o m past m e d i c a l / p s y c h o l o g i c a l records of the i n d i v i d u a l , ( i n c l u d i n g s tandard i zed assessment inst ruments) . In a d d i t i o n , factors g leaned f r o m the research l i te rature were inves t igated f o r a p p l i c a b i l i t y to the case subject. T h e factors were e l i c i ted through an i n t e r v i e w 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 us ing statements of the case subject , f a m i l y and f r i e n d s . - 9 - C H A P T E R II REVIEW OF T H E L ITERATURE 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 homosexuality . . . . Transsexualism is something different in kind. It is not a sexual mode or preference. 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 ranssexua l i sm (transvestites or homosexuals request ing sex - reass ignment surgery [SRS]) ( B a l l , 1981; R o t h and B a l l , 1964). B e n j a m i n (1966) developed a seven-category "Sex O r i e n t a t i o n Scale," d e s c r i b i n g what 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 . T h e f i r s t category was in part descr ibed as " . . . any person of no rmal sex and gender o r ien ta t ion for w h o m ideas of cross -dress ing or sex change are complete ly f o r e i g n and d e f i n i t e l y unp leasant , whether the person is hetero, b i - or homosexua l " ( in O lcs , 1977, p . 68). T h e r e m a i n i n g categories f o l l o w e d f r o m this extreme a long the c o n t i n u u m and were represented as: Pseudo T ransvest i te , F e t i s h i s t i c T r a n s v c s t i t c , T rue T r a n s v c s t i t e , N o n - S u r g i c a l T r a n s s e x u a l , T r u e T r a n s s e x u a l — M o d e r a t e Intensi ty and T r u e T r a n s s e x u a l — H i g h Intensity . T h e latter six categories a l l shared the ou tward b e h a v i o r of c ross -dress ing but w i t h v a r y i n g degrees of i d e n t i f i c a t i o n w i t h the cross-gender as we l l as f r e q u e n c y of the behav ior . T h e use of the more recent term 'gender d y s p h o r i a s y n d r o m e ' ref lects this not ion of a c o n t i n u u m and range of behav iors , mot i va t ions and at t i tudes w h i c h arc presented by i n d i v i d u a l s request ing sex - reassignment (Olcs , 1977). Gender d y s p h o r i a as a category subsumes not on ly that of t ranssexual but the ent i re range of i n d i v i d u a l s who may at some t ime have cross-gender desires. T h i s group w i l l i n c l u d e select t ransvest i tes and some e f f e m i n a t e homosexuals and mascul ine lesbians (Steiner , 1985). T r a n s s e x u a l i s m may be v iewed as an extreme of the gender d y s p h o r i a syndrome. T h o u g h the t ranssexual may have cer ta in charac te r i s t i cs in 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 this 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 their incons is tency of cross- gender desire and associated negat ive a f f e c t (i.e. a n x i e t y and react ive depression) (Steiner , 1985). A more recent c l a s s i f i c a t i o n system now in use at the C l a r k e Institute of P s y c h i a t r y focuses on the va r ia t ions of gender d y s p h o r i a presented. These arc: - 11 - t ransvest i te , heterosexual t ranssexua l , asexual t ranssexual and homosexual t ranssexual (Steiner , 1981). A l l f o u r categories have in c o m m o n the behav ior of c ross -dress ing . The t ransvest i te i n d i v i d u a l is d e f i n e d as a heterosexual male who achieves f e t i s h i s t i c arousal by w e a r i n g var ious i tems of f e m i n i n e a t t i re . T h o u g h at t imes the t ransvest i te may exper ience gender d y s p h o r i c fee l ings , these are usual ly of a t rans i to ry nature and consequent ly the i n d i v i d u a l is not cons idered to be e i ther t ranssexual or a good cand ida te fo r S R S . H o w e v e r , there are recorded cases of d iagnosed transvest i tes who in m i d d l e age deve lop in to t ranssexuals (at w h i c h t ime the d iagnos is changes). T h e latter three categories a l l exper ience ongo ing gender d y s p h o r i a : they d i f f e r in sexual o r i e n t a t i o n (object choice) and 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 ranssexual . F r o m this s tandpo in t they arc a l l cons idered potent ia l cand idates for S R S (Steiner, 1985). A t t e m p t s to c l a s s i f y in terms of e i ther of these and other schema have taken a va r ie t y of fo rms. These have i n c l u d e d sc reen ing processes stressing m u l t i d i s c i p l i n a r y i n t e r v i e w techniques, i n c l u d i n g s o c i a l , p s y c h o l o g i c a l , p s y c h i a t r i c and n e u r o e n d o c r i n o l o g i c a l assessments (Lothste in 1980; W e a t h c r h c a d , Powers, Rodgers , S c h u m a c h e r , B a l l a r d , and H a r t w e l l , 1978). In both of these studies c i ted , 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 iagnos is , acceptance to the p rogram of S R S , and f o l l o w - u p on post -surg ica l adjustment . L o t h s t e i n (1980) s p e c i f i c a l l y addressed the need fo r psychotherapy f r o m the t ime of d iagnos is through surgery (and a f te r ) , so as to f a c i l i t a t e i m p r o v e d adjustment to the new role. Weatherhead et a l . (1978) reported that c o u n s e l l i n g was a requi rement of the i r p rog ram at the C l e v e l a n d C l i n i c . It was c a r r i e d out by a p s y c h i a t r i c socia l w o r k e r fo r a m i n i m u m of s ix months p re -opera t i ve l y , and post o p c r a t i v e l y , fo r an undescr ibed per iod of t ime. They stated that c o u n s e l l i n g served severa l purposes: (1) to support pat ients in ad jus t ing to the soc ia l e n v i r o n m e n t as they begin the process of f u l l t ime c r o s s - l i v i n g ; (2) to develop a c o u n s e l l i n g e n v i r o n m e n t of total - 12 - acceptance where the pat ient feels f ree to exp lore a l l areas of self doubt (whether or not they are re lated to t ranssexual ism) ; (3) to mon i to r the c o n t i n u e d m o t i v a t i o n of the pat ient ; (4) to a l l o w fo r an ongo ing in tens ive e v a l u a t i o n and assessment of the pat ient . D u r i n g this process the team psychologist w o u l d a d m i n i s t e r the T h e m a t i c A p p e r c e p t i o n Test. D a t a generated f r o m this test w o u l d be supp l ied to the therap is t fo r f u r t h e r e x p l o r a t i o n ( i f not a l ready covered) d u r i n g therapy . Once at the po int where the therapist was prepared to c o m m i t the pat ient to the stage of S R S , they (the therapist ) w o u l d refer the pat ient back to the team psych ia t r i s t for another 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 battery) . If the psych ia t r i s t was in agreement, the case was then put f o r t h to the t reatment team as a whole . If the ent i re team agreed, the pat ient/c l ient was recommended for surgery . Quest ions cou ld be raised regard ing how therapists at the C l e v e l a n d C l i n i c were able to p rov ide therapeut ic env i ronments of " total acceptance" when they were s imu l taneous l y c o n d u c t i n g assessments w h i c h w o u l d con t r ibu te to a r e c o m m e n d a t i o n fo r or against surgery. Weatherhead et a l . (1978) d i d not discuss this c o n c e r n , and how it was dealt w i t h in the i r p rogram. S h u m a k e r , in c h r o n i c l i n g her exper iences as a pre- and then post operat ive m a l e - t o - f e m a l e t ranssexual ( L e v i n e and S h u m a k e r , 1983), addressed d i r e c t l y this issue of the t h e r a p u t i c re la t ionsh ip . In d e s c r i b i n g her p r e - o p c r a t i v c therapy (w i th L e v i n e , her later co -author ) she stated that she consc ious ly l i m i t e d the therapeut ic exper ience , be ing a lways s l igh t l y suspic ious of her therapis t , w h o m she knew to ho ld much power over her a b i l i t y to a t ta in the S R S . It is S h u m a k c r ' s content ion that had p re -opera t i ve therapy been e f f e c t i v e at a deeper leve l , it might have helped to prepare her fo r the post operat ive rea l i t ies (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 face. - 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 and at t imes c o n t r o v e r s i a l , has been cent ra l in both issues of d iagnos is and adjustment . K e l l e r , A l t h o f and Lo ths te in (1980) conducted a fou r year study of the e f f i c a c y of group therapy w i t h p roc la imed male and female t ranssexuals (al l p re -operat ive) . A s a sc reen ing dev ice , the m o d a l i t y of long term group therapy was seen as be ing h i g h l y e f f e c t i v e . Over the per iod of s tudy , 4 3 % of the par t i c ipants opted out of the p r o g r a m a n d , in e f f e c t , out of surgery . T h e authors c l a s s i f i e d these as instances of t ransvest ism. It is in te res t ing to note that the group that d ropped out tended to be o lder (mean age 35) wh i te males. What u l t i m a t e l y became of the p rogram dropouts and whether f o l l o w - u p was done w i t h them was not e x p l a i n e d by the authors . M o r g a n (1978) presented his e f f o r t s in an ongo ing process of c l a s s i f i c a t i o n , w h i c h i n c l u d e d an i n i t i a l d iagnos is , f o l l o w e d by f u r t h e r r e f i n e m e n t 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 appropr ia te for S R S , f r o m those w h o m he judged wou ld benef i t f r o m psycho log ica l fo rms 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 gender i d e n t i t y " (as d e f i n e d by Sto l le r , 1968) is a c o n t i n u u m on w h i c h we a l l reside. E x p e r i e n c e , he reports, has shown h i m that the hypothe t i ca l and c lass ic case of the a n a t o m i c a l male who v iews his penis as some type of growth capable of g i v i n g h i m no pleasure, who has a lways thought of h i m s e l f as a w o m a n , who presents c o n v i n c i n g l y to the w o r l d as such , is a very s t r a i g h t - f o r w a r d but ex t remely rare case (p. 274). T h e m a j o r i t y of pat ients who present as transsexuals (se l f -d iagnosed) do not f a l l at this ext reme of the c o n t i n u u m , but rather somewhere closer to the centre. A s a result , c l a s s i f i c a t i o n and d iagnos is is a process w h i c h requires an intense e v a l u a t i o n over an extended per iod of t ime. M o r g a n says that the c l i n i c i a n , when engag ing these i n d i v i d u a l s in this ongo ing process of e v a l u a t i o n and t reatment , must be prepared to deal w i t h what he has termed "the t ranssexual 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 , and sometimes h y s t r i o n i c pursu i t of SRS) . He estimates that as an outcome 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 ranssexual cand idates 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 major menta l i l lness, 3 0 % w i l l be classed as 'homophob ic homosexuals ' a t t e m p t i n g to escape a sexual o r i e n t a t i o n they f i n d abhor rent , and 2 0 % - 2 5 % are sexua l l y a m b i g u o u s i n d i v i d u a l s who are g iven the d iagnosis of " inadequate personal i ty . " T h i s latter g roup , M o r g a n suggests, are correct i n the i r assessment that they must make some p r o f o u n d changes i f they are to ach ieve any sense of s a t i s f a c t i o n and happiness f r o m l i f e ; they are i n c o r r e c t , however , in l a b e l i n g it as an issue so lvab le by s u r g i c a l gender t r a n s f o r m a t i o n . In d iscuss ing why 6 5 % - 7 0 % of i n d i v i d u a l s present ing as t ranssexual 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 returns to his concept of "the t ranssexual imperat ive . " He points out that diagnoses such as s c h i z o p h r e n i a , inadequate personal i t y and homosexua l i t y c a r r y c lear negat ive connotat ions . 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 iagnosis l i k e 'acute append ic i t i s . ' A f t e r surgery the d iagnosis goes a w a y . A f t e r the surgery the t ranssexual is a ' w o m a n , ' a cons iderab le i m p r o v e m e n t over be ing 'c razy , ' ' inept , ' or 'queer , ' in the minds of most. The i m p e r a t i v e of the t ranssexual cand ida te is an echo of the societal i m p e r a t i v e to be ' n o r m a l , ' ' regular , ' and 's t ra ight , ' as this society def ines these terms, (p. 281) Desc r ip t ions of behav io r , congruent w i t h Morgan 's concept of the t ranssexual i m p e r a t i v e , can be f o u n d in the wr i t ings of a number of other authors (e.g. B a l l , 1981). F o l l o w i n g M o r g a n (1978), Meyer (1983) c lea r l y stated that in his o p i n i o n , appropr ia te d iagnos is takes place w i t h i n the f r a m e w o r k of ongo ing (and re la t i ve l y long term) psychotherapy . M e y e r , in d e s c r i b i n g his p r o g r a m , said that i f the prospect ive pat ient was accepted into the p rog ram, he or she was then i m m e d i a t e l y - 15 - r e f e r r e d to e i ther group or i n d i v i d u a l therapy (as a prerequ is i te to any f u r t h e r 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 of appropr ia te hormones) . It shou ld be noted that i n d i v i d u a l s accepted into this p rog ram were g iven no guarantees of S R S as a f i n a l outcome. M e y e r said that d iagnos is of the ' true t ranssexua l ' took place over the course of the week ly therapy sessions. Cons idered in this d iagnos is was how we l l a sense of f e m i n i n e i d e n t i t y was in tegrated (in the case of a b i o l o g i c a l male) as w e l l as the i n d i v i d u a l ' s a b i l i t y to deal w i t h f r u s t r a t i o n , and to 'b ide t ime. ' M e y e r stated that the c a n d i d a t e w i t h the best prognosis was one w i t h a real u n d e r s t a n d i n g of the d i f f i c u l t i e s to be faced once this t r a n s f o r m a t i o n was complete. He went 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 personal m a t u r i t y , may possib ly have been cor re la ted w i t h the s t a b i l i t y of the cross gender ident i t y . In this p rog ram (Meyer , 1983) only 5 % to 10% of cand idates a c t u a l l y opted for the comple t ion of S R S . Other reported results i n c l u d e d : permanent passing w i thout surgery , or passing w h i l e w a i t i n g for i m p r o v e d surg ica l techniques ; l i v i n g (at d i f f e r e n t t imes) as both sexes, and set t l ing on ne i ther ; reso lut ion of the d y s p h o r i a and permanent return to the o r i g i n a l gender. E f f o r t s at the c reat ion of a common psycho log ica l p r o f i l e th rough the use of such s t a n d a r d i z e d measures as the M inneso ta M u l t i p h a s i c P e r s o n a l i t y Inventory , C a l i f o r n i a P e r s o n a l i t y Inventory and T h e m a t i c A p p e r c e p t i o n Test , have y ie lded no consistent results (Weatherhead, et a l . , 1978). O t h e r e f f o r t s at seek ing common charac te r i s t i cs across subjects suggest that the most o u t s t a n d i n g charac te r i s t i c of people d iagnosed as t ranssexual is a narc iss is t ic 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 by submiss ion and p s e u d o - f e m i n i n i t y " (Sorenson and H e r t o f t , 1982, p.142). T h i s was observed in c o n j u n c t i o n w i t h a suppress ion of aggressive and sexual fee l ings (Sorenson and H e r t o f t , 1982). In a d d i t i o n to th is , the other common - 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. The twelve factors hypothesized were: psychosis, mental retardation, unstable personality, alcoholism/drug addiction, 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 can be seen f r o m the p reced ing d iscuss ion , the issue of c l a s s i f i c a t i o n and d iagnos is is s t i l l p r o b l e m a t i c . B a l l (1981), in d e s c r i b i n g his exper ience of w o r k i n g w i t h t ranssexuals over the past t h i r t y years, suggested that it appears that this issue has become more c o m p l i c a t e d rather than less so. In his o r i g i n a l work in the m i d 1950's, the m a j o r i t y of people request ing sex - reass ignment appeared re la t i ve l y homogeneous as compared w i t h the present ing p o p u l a t i o n today. He charac te r i zed them as be ing of above average in te l l i gence , ex t remely de te rmined to complete the process, and w i t h "h igh personal asp i ra t ions w h i c h were thwar ted by thei 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 Sca le ' the subjects scored h igher on f e m i n i n e interest scales than d i d a matched group of women. In his a r t i c l e , B a l l po inted out that at that t ime, very l i t t le of the work in this area had been p u b l i s h e d by the popular press, w i t h the except ions of the Jorgcnson and C o w e l l cases, w h i c h had just recent ly been reported. He descr ibed this i n i t i a l g roup as be ing la rge ly se l f - se lec t ing . A s the study of t ranssexua l i sm and S R S has increased i n the p u b l i c consciousness, the pat ient p r o f i l e request ing surgery has become more heterogeneous rather than homogeneous. Research on E t io logy T h e issue of 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 establ ish cause/et io logy of the syndrome (as we l l as w i t h t reatment outcome). Repor ted i n c i d e n c e of what w o u l d appear to be t ranssexual ism has been recorded throughout h is tory (Steiner 1981). E a r l y theorists hypothes ized that the cause of the phenomenon lay in some f o r m of pathogenic re la t ionsh ip between mother and son. M o d e r n research has not supported this hypothesis ( B u h r i c h and M c C o n a g h y , 1978). These ear ly theories focused on b i o l o g i c a l males, due to the be l ie f that they were the great m a j o r i t y , i f not the total phenomenon. Stat is t ics now show that the d i s p a r i t y between males and females d iagnosed as t ranssexual 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 research, relates not so much to the role of the mother but rather , to the absence, i n a b i l i t y or d is interest of the father to f u n c t i o n adequate l y w i t h i n the paterna l role (Bernste in , et. a l . , 1981; B u r i c h and M c C o n a g h y , 1978; S ipora and B r z e c k , 1983; Sto l le r , 1979). In a d d i t i o n to invest igat ions w h i c h have s tud ied p s y c h o l o g i c a l d y n a m i c s w h i c h c o u l d c o n c e i v a b l y result in the deve lopment of the t ranssexual syndrome, inves t igat ions have also addressed possible b i o l o g i c a l factors in the et io logy of this syndrome. Sto l le 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 io log ica l ) f a c t o r must be present fo r the syndrome to u n f o l d . T h i s fac tor may operate in c o n j u n c t i o n w i t h psychosoc ia l factors present, but in Sto l lc r 's e s t i m a t i o n , the latter (the psychosoc ia l factors ) , in and of themselves, w i l l not produce the syndrome. T h i s concept was the result of his study of cross-gender i d e n t i t y , presented in a s m a l l n u m b e r of intersexes (hermaphrod i tes and pseudo -hermaphrod i tes ) . H o c n i g (1985), in his rev iew of the research into b i o l o g i c a l antecedents po inted out that Sto l ler 's not ions of the impor tance of the b i o l o g i c a l fac tor were supported by M o n e y , H a m p s o n and H a m p s o n (1957). H o e n i g , in his e x p l i c a t i o n of the i r research, stated that it supported the pos i t ion of a ' n e u t r a l i t y ' of gender i d e n t i t y at b i r t h . M o n e y , H a m p s o n and H a m p s o n (1957) argued that the deve lopment of gender i d e n t i t y took place through the process of i m p r i n t i n g . S ince i m p r i n t i n g , u n l i k e c o n d i t i o n i n g , is genet ica l l y f i x e d and spec ies - spec i f i c , the f o r m a t i o n of gender i d e n t i t y is then an issue of a genet ica l l y i nher i ted p red ispos i t ion w h i c h is released or t r iggered by c e r t a i n psychosoc ia l events w h i c h occur in the presence of the i n d i v i d u a l . H o e n i g (1985) showed that there is anecdota l ev idence suggest ing that epi lepsy w i t h a c c o m p a n y i n g tempora l lobe lesions occurs more f r e q u e n t l y in the t ranssexuals than in other sub-groups of the p o p u l a t i o n . H o e n i g a c k n o w l e d g e d that such reports were h igh l y tentat ive and their s i g n i f i c a n c e was (and remains) - 19 - unc lear . H o e n i g and K e n n a (1979), s t u d y i n g the E E G patterns of a group of 56 t ranssexuals (35 male and 11 female ) , d i d conc lude that there were a b n o r m a l patterns in a d i s p r o p o r t i o n a t e l y large segment of the subjects (48% showed clear a b n o r m a l i t i e s w h i l e 2 4 % were border l ine) . 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 ther the le f t or r ight tempora l area. H o e n i g a c k n o w l e d g e d that this f i n d i n g was not necessar i ly consistent w i t h other research (when E E G a b n o r m a l i t i e s have been repor ted , they have not a lways centered in the tempora l lobe area). E x p l a n a t i o n s fo r the incons is tency of these f i n d i n g s as wel l as for their s i g n i f i c a n c e to the et io logy of the syndrome are not f o r t h c o m i n g as yet. A s H o e n i g po inted out , despite the incons is tency in inc idence of E E G a b n o r m a l i t y , e levated levels of a b n o r m a l i t y have now been reported across a var ie ty of studies (e.g. W a l i n d e r , 1965; B l u m e r , 1969; R a n d c l l , 1970; K o c k o t t and Nussc l t , 1976; H o e n i g and K e n n a , 1 9 7 9 ) . 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 accounted for i n f u t u r e theoret i ca l f o r m u l a t i o n s . A t t e n t i o n has been focused 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 iscover a b n o r m a l i t i e s w h i c h cou ld e x p l a i n the deve lopment of t ranssexual ism. These i n c l u d e studies of ho rmona l imbalances resu l t ing in m a l d c v e l o p m c n t in the h y p o t h a l m i c reg ion ( N e u m a n n , 1970). A n o t h e r stream of research has focused on an androgen d e f i c i e n c y d u r i n g the second and t h i r d t r imester of feta l deve lopment , resu l t ing in what is descr ibed as a " f e m i n i z e d " b r a i n . T h i s theory states that g iven c e r t a i n e n v i r o n m e n t a l tr iggers in c o n j u n c t i o n w i t h this sex- d i f f e r e n t i a t e d b r a i n , the result is the deve lopment of t ranssexua l i sm (Dorner , R o h d e , S e i d e l , Haas , and Schott , 1976). H o e n i g (1985), in his rev iew of these two studies, po inted out that both theories were based on results ex t rapo la ted f r o m a n i m a l studies, w h i c h leave them open to some quest ion . C o m m e n t i n g on the latter of the two studies, he stated that the existence of a s e x - d i f f c r e n t i a t c d b r a i n in - 20 - humans has never been demonstrated to exist . O v e r a l l he expressed grave doubts that gender i d e n t i t y cou ld be understood by observ ing b e h a v i o r a l t ra i ts in an imals . H o e n i g (1985) goes into some deta 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 ant igen a b n o r m a l i t i e s in both male and f e m a l e t ranssexuals . E n g e l et a l . (1980) have reported the occur rence of H - Y ant igen 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 number of t ranssexuals s tud ied . H - Y ant igen has been shown to be s i g n i f i c a n t in the establ ishment of sex. A s yet however , these researchers are not able to o f f e r any documented ra t iona le for the role of H - Y ant igen in the deve lopment of gender ident i t y . A s this b r ie f rev iew of some of the representat ive studies in this area shows, there exist some in terest ing ear ly f i n d i n g s , but as yet no conc lus ive statements of b i o l o g i c a l , psycho log ica l or in te rac t i ve pathways of et io logy may be made. Research on T r e a t m e n t Outcome L o t h s t e i n (1980) s tud ied 21 b io log ica l male t ranssexuals who had completed sex - reass ignment surgery . G r o u p I completed the surgery p r io r to the o r g a n i z a t i o n of the Case Western Reserve U n i v e r s i t y ( C W R U ) G e n d e r Ident i ty C l i n i c , and G r o u p II had surgery a f te r the c reat ion of the c l i n i c . The 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 patient and to p rov ide ongo ing psychotheraput ic support p r io r to, d u r i n g and af ter surgery . In the two year f o l l o w - u p af ter S R S , 5 7 % of G r o u p I who had been employed p r i o r to surgery , were unemployed in the f o l l o w - u p per iod . There was also a c o m m o n theme of soc ia l i so la t ion , and at best on ly m a r g i n a l re la t ionsh ips w i t h people. T h e f o l l o w - u p procedures for G r o u p II were more deta i led and consequent ly not a l l of the results were d i r e c t l y comparab le to G r o u p 1; nonetheless, G r o u p II showed a 6 5 % improvement in work ad jus tment , 2 9 % no - 21 - change a n d 7% showed a negat ive change. In terms of re la t ionsh ips there was no ev idence of s i g n i f i c a n t pos i t i ve improvement in soc ia l re la t ionsh ips . A s w i t h the f i r s t g roup , they tended to be soc ia l l y iso lated. Despi te reports of subject ive s a t i s f a c t i o n , pat ients i n G r o u p II e x h i b i t e d m u l t i p l e fears s u r r o u n d i n g their new ident i t ies a n d the adequacy of the i r genitals . A f u l l 5 0 % of pat ients reported i n c i d e n t s of recur rent images of ' phantom penises' up to two years f o l l o w i n g surgery (the d u r a t i o n of the study) . There were also reports of e jacu latory sensations despite the p h y s i o l o g i c a l ev idence (the remova l of male tissue) of the i m p o s s i b i l i t y of this . A m o n g this group, there were also reports of ep isodic depression and thoughts of su ic ide ( though no actua l su ic ides occur red d u r i n g the t ime of the study) . Lo ths te in reported that there were no changes in character s t ructure or p s y c h i a t r i c d iagnosis in e i ther post -surgery group. B c h a v i o r a l l y , he reported that in the post operat ive per iod less s tereotyp ica l rec reat ion and social a c t i v i t i e s were engaged i n . T h o u g h the lack of a cont ro l group l i m i t e d the g e n e r a l i z a b i l i t y of the results f r o m G r o u p II, Lo ths te in (1980) suggested that in this study there was an o v e r a l l i m p r o v e m e n t rate of a p p r o x i m a t e l y 6 5 % . He po inted out that it was d i f f i c u l t to separate the e f fec ts of S R S f r o m the e f fec ts of psychotherapy in r e v e a l i n g w h i c h factors had resulted in the improvement rate. He also a c k n o w l e d g e d that this was a se l f - se lec t ing group who w o u l d submi t to the requ i rements of a gender ident i t y p rog ram, and may have been s i g n i f i c a n t l y 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 who wou ld have chosen to go through a pr ivate p r a c t i t i o n e r who w o u l d not place the same requi rements on them. T h o u g h Lothste in 's (1980) results demonstrated improvement on s p e c i f i c d imens ions , the f i n d i n g s remained somewhat m i x e d when contrasted w i t h the subject ive rat ings of post operat ive sa t i s fac t ion 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 reported be ing ext remely sa t i s f ied . N o t i n g th is , Lo ths te in c i ted prev ious - 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 improvement f o l l o w i n g surgery ( B e n j a m i n , 1966; R a n d a l l , 1969). L a c k of s t a n d a r d i z a t i o n in r a t i n g procedures appeared to be one of the factors in these c o n f l i c t i n g results. H u n t and H a m p s o n (1980), i n a study of post operat i ve pat ients (mean of 8.2 years) , c o u l d demonstrate no s i g n i f i c a n t changes in levels of psychopatho logy and on ly modest gains in terms of economic f u n c t i o n i n g and in te rpersona l re la t ionsh ips . M o r e s t r i k i n g changes (posit ive) occur red in sexual s a t i s f a c t i o n and f a m i l y acceptance. T h e i n c l u s i o n of subjects demonst ra t ing psychopatho logy in this s tudy s t rong ly 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 rev ious l y c i ted w o r k , yet one may suggest that the existence or non-ex istence 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 surgery 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 , Salt , Jones, and Jenk ins (1981) f o u n d a s i g n i f i c a n t l y h igher level of psycho log ica l f u n c t i o n i n g ( M M P I scores) in post operat ive subjects, compared w i t h test ing in p re -opcra t i ve periods. The authors d i d not suggest f r o m this result that S R S is capable of c u r i n g symptoms of menta l i l lness , but rather , may have a pos i t i ve e f f e c t on non -psychopatho log ica l f u n c t i o n i n g . A t t e m p t s have been made to in t roduce a s t a n d a r d i z e d r a t i n g system to invest igate pre- and post -surg ica l adjustment (Hunt and H a m p s o n 1980). In spite of the a l r e a d y ment ioned issue of the i n c l u s i o n of subjects e x h i b i t i n g p s y c h o p a t h o l o g i c a l symptoms, the i r d imens ions for f a t i n g (economic , in terpersonal re la t ionsh ips , psychopatho logy , sexual ad justment , a d d i t i o n a l surgeries and procedures , and cur rent f a m i l y reactions) begin to address the need for commonness in r a t i n g and f o l l o w - u p . T h i s broader focus in r a t i n g success/fa i lu re , is also i m p o r t a n t in terms of a move away f r o m the nar row focus of solely medica l and/or p s y c h o l o g i c a l assessments for i n t e r v e n t i o n , t reatment and e v a l u a t i o n . Hast ings and M a r k l a n d (1978), t racked t w e n t y - f i v e m a l e - t o - f e m a l c t ranssexuals as part of a ten year s tudy , They also o f f e r e d a scheme for assessing - 23 - pos t - su rg ica l success. R a t i n g on f o u r d imens ions : s o c i a l , e m o t i o n a l , sexual and economic , each d i m e n s i o n was scored as excel lent , good, f a i r or poor. R e p o r t i n g at the m i d - p o i n t of the study ( f i ve years post opera t i ve l y ) , they f o u n d that consistent w i t h other f i n d i n g s , the subject popu la t ion u n a n i m o u s l y agreed that they were pleased at h a v i n g completed the process of S R S . Immediate post operat i ve results i n c l u d e d a sense of re l ie f at " f i n a l l y being a woman , " surpr ise at the degree of pos t - su rg ica l p a i n , and interest in mammaplas ty and car t i lage s h a v i n g of the adams apple . N o post operat i ve d e l i r i u m , psychot ic react ions or occurrences of 'phantom penises' were witnessed in this group. 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 not repor ted , other than to say that subjects who rated an o v e r a l l poor to f a i r r a t i n g were c h a r a c t e r i z e d as h a v i n g "high soc iopath ic l o a d i n g of personal i ty s t ructures p r i o r to surgery" (p. 33). Hast ings and M a r k l a n d stated that in their sample the area of romance proved to be the most d i f f i c u l t and p r o b l e m a t i c to post operat i ve ad justment (whether overa l l h igh or low rat ings) . T h i s may be consistent w i t h a p r e v i o u s l y c i ted study (Lo ths te in , 1980) w h i c h stressed the charac te r i s t i c of soc ia l i s o l a t i o n . Some studies s h o w i n g i m p r o v e d soc ia l ad jus tment (VVeatherhcad, D i x o n , et a l . , 1978) were f o u n d to be vague in the i r d e f i n i t i o n of ' i m p r o v e d socia l ad justment . ' T h e s ing le most i n f l u e n t i a l and cont rovers ia l research project of the 1970's has come to be k n o w n as "The H o p k i n s Repor t " (Meyer and R e t c r , 1979). The "Johns H o p k i n s G e n d e r Ident i ty C l i n i c and C o m m i t t e e " was establ ished in 1965, h a v i n g dealt w i t h t ranssexual pat ients for the prev ious f i v e years. Meyer and Reter (1979) began the study in 1971 in an attempt to " . . . step back f r o m the n o r m a l i z a t i o n of sex - reass ignment procedures in order to look ob jec t i ve l y at the long - range e f fec ts of surgery" (p. 1010). B e g i n n i n g w i t h 34 operated and 66 unoperatcd pat ients the researchers set out to assess (us ing p r i m a r i l y in terv iews) the f u n c t i o n i n g of operated subjects - 2 4 - before a n d a f te r surgery . T h o u g h not a str ict ' cont ro l g roup, ' the unoperated sample o f f e r e d some basis f o r compar ison . D u r i n g the data c o l l e c t i o n per iod (three years) a t h i r d group emerged: subjects who were operated on d u r i n g the course of the study . U l t i m a t e l y , 52 in te rv iews were comple ted , across the three groups. F o l l o w - u p scores were ca lcu la ted (based on concrete behav iors ) on each of four d imens ions : lega l , economic , m a r r i a g e / c o h a b i t a t i o n and p s y c h i a t r i c . F r o m these d i m e n s i o n scores, an o v e r a l l change score fo r each subject , and mean change scores fo r each group were c a l c u l a t e d . T h e results showed that there was a pos i t i ve s h i f t o v e r a l l for each of the three groups, a c c o m p a n i e d by a n a r r o w i n g of s tandard dev ia t ions . The change scores, between groups, were not s i g n i f i c a n t . Change scores fo r operated pat ients (those o r i g i n a l l y tagged as operated as opposed to those who subsequent ly became 'operated' ) were not s i g n i f i c a n t (p<1.0). U n o p e r a t e d pat ients d i d achieve s i g n i f i c a n t change scores (p<.001). The subsequent ly operated group fa red the worst of the three in o v e r a l l change (mean, -0.4). The authors c o n c l u d e d that S R S resulted in no ob ject ive advantage in terms of socia 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. The passage of t ime wou ld a f f e c t improvement in the soc ia l f u n c t i o n i n g of 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 wou ld not. A b r a m o w i t z (1986), in r e v i e w i n g the last two decades of e m p i r i c a l work in the area o f outcome of sex - reassignment surgery , devoted a sect ion of his rev iew to the H o p k i n s R e p o r t and the c r i t i c i s m s of it. C i t i n g 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 quest ioned the a rb i t ra r iness of the outcome categories. For example , l i v i n g a lone was cons idered less adjusted than 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 judged appropr iateness of the partner 's (spouse's) gender. F o r example , fo r a post operat i ve m a l c - t o - f e m a l c t ranssexual to be judged as successfu l on this d i m e n s i o n , the partner wou ld be male. T h e couple were then v iewed as l i v i n g in an ' a p p r o p r i a t e ' heterosexual - 2 5 - r e l a t i o n s h i p . T h e post operat i ve i n d i v i d u a l l i v i n g w i t h a w o m a n , in a lesbian r e l a t i o n s h i p , appears to have been judged as h a v i n g a 'gender i n a p p r o p r i a t e ' re la t ionsh ip . F l e m i n g et a l . (1980) went on to note that each d i m e n s i o n had a d i f f e r e n t number of response categories and d i f f e r e n t possible score ranges, therefore caus ing d i f f e r e n t components to have unequa l rat ings . Bas ing their deduct ions on possible score ranges and actua l reported 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 ce r ta in negat ive events f i g u r e d c u m u l a t i v e l y but that the d u r a t i o n of events were ignored . Examples of the r a m i f i c a t i o n s of this were supp l ied by the authors : two arrests were worse than one (d i s regard ing the sever i ty of the charges) ; two hosp i ta l i za t ions were worse than one whatever the durat ions of the h o s p i t a l i z a t i o n s might 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 correct in their deduct ions , the c o n f o u n d of d i f f e r e n t lengths of t ime fo r f o l l o w - u p (an average of 5 years in the operated group and 2 years for the unopcrated group) was s i g n i f i c a n t . If the negat ive events were weighted 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 negat ive po ints , so to speak. He went on to express amazement that such an e lementary psychomet r i c error cou ld have escaped both the authors and the o r i g i n a l rev iewers . He c o n c l u d e d however , that it d i d appear that the ca l cu la t ions of the H o p k i n s Repor t were biased against the p r i m a r y su rg i ca l group and therefore 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 methodo log ica l c r i t i c i s m s e x c l u s i v e l y fo r the H o p k i n s Repor t . R e s u l t i n g f r o m his rev iew of this body of l i te ra tu re , he stated that depar tures f r o m the usual s c i e n t i f i c procedures were a l l too f requent . A s an example he noted that cont ro l groups were an i n n o v a t i o n i n t r o d u c e d on ly in the p rev ious f i v e years. Without the use of r igorous cont ro l groups, a t t r i b u t i n g e i ther success or d e t e r i o r a t i o n to the in te rvent ion of sex - rcass ignment surgery is s c i e n t i f i c a l l y i n d e f e n s i b l e . 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 - d i f f i c u l t y and sometimes i m p o s s i b i l i t y of c r e a t i n g these cont ro l groups. He expressed less s y m p a t h y w i t h other pract ices d iscovered in the l i te ra tu re . We are t y p i c a l l y le f t in the dark about such o b v i o u s l y c r i t i c a l subject va r iab les as p s y c h i a t r i c status and d iagnos is , extent of gender r e o r i e n t a t i o n , and prev ious ear ly -s tage sex-change procedures. Subjects i n c l u d e d in subsequent reports by the same invest igator sometimes appear to over lap w i t h samples f r o m ear l ie r series. I n c r e d i b l y , subjects who c o m m i t t e d su ic ide are o c c a s i o n a l l y not i n c l u d e d in c o m p u t a t i o n of the improvement rate because they were not a v a i l a b l e for f o l l o w - u p . . . . The research is r i f e w i t h v i o l a t i o n s of genera l l y acceptable assessment pract ices , (p. 184) A b r a m o w i t z d i v i d e d the research into two methodo log ica l groups: prc - 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 . Outcome reports in the p r c - q u a n t i t a t i v e studies (10 studies rev iewed) showed that 6 0 % to 8 5 % of pat ients were rated as improved or s a t i s f i e d . A total of 14 serious compl i ca t ions (de f ined as a reversal request, a psychot i c episode, h o s p i t a l i z a t i o n , or su ic ide) were reported in the ten studies (6.4% of the total subjects). The strongest pos i t ive results were on d imens ions of cosmet ic s a t i s f a c t i o n , in te rpersona l re la t ionsh ips and psycho log ica l w e l l - b e i n g . Less p r o n o u n c e d i m p r o v e m e n t was reported in areas of w o r k , economics , legal and sexua l re la t ionsh ips . In r e v i e w i n g these studies, A b r a m o w i t z (1986) c a u t i o n e d the reader that this body of research d i d not incorporate psychometr ic ins t ruments , and u n i v e r s a l l y , the authors had s i g n i f i c a n t personal investments in the outcomes. O n a pos i t ive note, he added that the results were strengthened by "wel l a r t i c u l a t e d outcome var iab les and potent ia l pat ient mediators" (p. 185). Without cont ro l groups, we arc - 27 - unab le to d r a w causal re la t ionsh ips between basel ine and outcome data and the e f f e c t of S R S . The q u a n t i t a t i v e studies inco rpora ted psychomet r i c inventor ies and s t a n d a r d i z e d r a t i n g scales. A tota l of four teen studies were r e v i e w e d in this sect ion . T h e average f o l l o w - u p per iod was f o u r years. Resu l ts of 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 thout the use of a cont ro l group supported the ear l ie r p r e - q u a n t i t a t i v e research and showed an average i m p r o v e m e n t rate of a p p r o x i m a t e l y t w o - t h i r d s (a range f r o m 5 0 % to 85%). O f the three q u a s i - e x p e r i m e n t a l studies reported ( 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 Sp i t z & Sal t , 1982; M e y e r and Rete r , 1979) two of the three reported s i g n i f i c a n t improvements in the su rg i ca l group (the t h i r d study was the p r e v i o u s l y discussed M e y e r and R e t c r , 1979). A s ingle study based on q u a n t i f i e d R o r s h a c h responses showed e q u i v o c a l results ( F l e m i n g , Jones & S imons , 1982). T a k e n as a group, the q u a n t i t a t i v e studies reported the greatest gains in the areas of sexual sa t i s fac t ions and re la t ionsh ips ( though a m i n o r i t y of studies, p rev ious l y c i t e d , cou ld demonstrate no s i g n i f i c a n t i m p r o v e m e n t in re lat ionships) . Less i m p r o v e m e n t was made in soc ioeconomic areas and in cosmet ic results. The lack of gains in cosmet ic results c o n f l i c t s w i t h the ea r l i e r ( p r c - q u a n t i t a t i v c ) research and is c o n f u s i n g in l ight of su rg i ca l advances of this t ime per iod . A b r a m o w i t z suggested that this result may be due less to the cosmet ic results themselves, and more to the lack of s t a n d a r d i z a t i o n in m e a s u r i n g it. In d i scuss ing the var iab les w h i c h may mediate outcome, this more recent group of studies (quant i ta t i ve ) , c lear l y supported the ear l ie r f i n d i n g (pre- q u a n t i t a t i v e ) , that character pathology is a negat ive f a c t o r in post operat ive prognosis. W a l i n d c r ct a l . (1978), as ment ioned before , demonst rated ev idence for other negat ive factors , i n c l u d i n g : inadequate f a m i l y support , c r i m i n a l records, o lder pat ients , i n a p p r o p r i a t e phys ique , and inadequate self support . - 28 - A b r a m o w i t z (1986) closed his r e v i e w of the last two decades of outcome research by say ing : Research is mere ly h u m a n behav io r , no more and no less, and every bit as subject to personal w h i m s and 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 incorporate proper cont ro ls as m o t i v a t e d f o r g e t t i n g , in the serv ice of r e t a i n i n g personal c o n t r o l over the u l t i m a t e i n t e r p r e t a t i o n of the results. Perhaps the absence of cont ro l groups need not be v i e w e d so harsh ly . A f t e r a l l , they are i m p r a c t i c a l (and sometimes uneth ica l ) in a d d i t i o n to be ing i n c o n v e n i e n t . T h e f a i l u r e to f o l l o w reasonable assessment pract ices , w h i c h are r e l a t i v e l y s imp le to ascer ta in , seems less easi ly understood w i t h o u t i n v o k i n g the not ion of ego invo l vement . A f t e r 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 of sex - reass ignment surgery , we have yet to see e i ther 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 dev ices to f a c i l i t a t e cross-study compar i son or the deve lopment of a m u l t i d i m e n s i o n a l i n v e n t o r y to tap the var ious s u b - d o m a i n s of postsurg ica l r e h a b i l i t a t i o n . . . . T h i s co l lec t i ve re luc tance to b r i n g s ta te -o f - the -a r t methods to bear on the d i f f i c u l t t reatment dec is ion becomes less p e r p l e x i n g , however , when we have recourse to sc icn t i s t - as -person var iab les in our model of the deve lopment of a research l i te ra tu re , (p.188-189) In th is rev iew of the l i te ra ture on t ranssexua l i sm, what has emerged is a series of e m p i r i c a l studies w h i c h have at tempted to focus 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 , e t io logy and treatment outcome. The results of w o r k in the areas of e t io logy and t reatment appear to be f r e q u e n t l y 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 ru ly s tandard a l though there does appear to be a general goal of es tab l i sh ing a w o r k i n g d e f i n i t i o n of a ' p r i m a r y ' or ' t rue ' t ranssexual . The studies of post -surg ica l f o l l o w - u p to d e t e r m i n e outcome have l a c k e d cons is tency of method and approach (Lo ths te in 1980, A b r a m o w i t z , 1986). It w o u l d appear that these issues are h i g h l y in te r re la ted . L a c k of agreement in areas of 'cause' and c l a s s i f i c a t i o n w i l l tend to foster incons is tency i n t reatment (psycho log ica l/psychosoc ia l , m e d i c a l or both) and consequent l y lead to incons is tency of focus in f o l l o w - u p . Oles (1977) presented a d iscuss ion of what she v iews as general psychotherapeut i c issues p e r t a i n i n g to work w i t h gender d y s p h o r i c i n d i v i d u a l s . T h i s paper resul ted f r o m her c l i n i c a l exper ience at the "Gender Ident i ty P r o g r a m " in San F r a n c i s c o . Whi le present ing an o v e r v i e w of such l a n d m a r k research as C a l d w e l l (1947), she focused p r i m a r i l y on var ious aspects of l i f e w h i c h impact on the i n d i v i d u a l . W o r k i n g f r o m the assumpt ion of gender i d e n t i t y res id ing on a c o n t i n u u m , and that surgery in some cases is the best o p t i o n , Oles discussed the impact of f a m i l y , c o m m u n i t y , employer , and other fac tors , on the people she has t reated in therapy . A t a more s p e c i f i c l eve l , she spoke of the impact of being ' r e a d ' on the street ( recognized as a t ranssexual ) be ing ar rested , c ross -dress ing at w o r k , as we l l as var ious responses f r o m f a m i l y , f r i e n d s and therapists . Y a r d l e y (1976), in r e v i e w i n g his work w i t h t ranssexuals , hypothes ized that acceptance by the therapist of the pre -operat i ve t ranssexual 's desire fo r S R S may be s i g n i f i c a n t in successfu l post operat ive a d a p t a t i o n . Both Y a r d l e y (1976) and Oles (1977) have addressed what can be termed as ' c o n t e x t u a l ' issues. Y a r d l e y , w i t h his hypothesis regard ing acceptance by the therapis t , and Oles in her d iscuss ion of the impact of the employer , the f a m i l y and the general p u b l i c , have both acknowledged that the i n d i v i d u a l does not l i ve in a v a c u u m , but rather , must exist and interact w i t h a var ie ty of i n d i v i d u a l s and - 30 - groups who 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 . T o a somewhat lesser extent this was also a c k n o w l e d g e d by Wa l inder et a l . (1978) w h o , in the i r focus on c o n t r a i n d i c a t o r s , l is ted (among others): lack of f a m i l y support , geographic d istance between the therapist and pat ient , and lack of personal support . S h u m a k e r ( L e v i n e and S h u m a k e r , 1978) reca l led her f rus t ra ted attempts to get appo in tments w i t h the gender i d e n t i t y c l i n i c s ta f f . When appo intments were secured , she repor ted that they f r e q u e n t l y i n v o l v e d be ing i n t e r v i e w e d by u n k n o w n , and (to her) , anonymous profess ionals . A t other t imes the appointments consisted of w r i t i n g test batter ies , the purposes of w h i c h were not e x p l a i n e d . She f i n i s h e d her d e s c r i p t i o n of these exper iences by say ing : "On ly K a f k a cou ld have designed such a torment of u n c e r t a i n t y " (p. 254). Mason (1980), a post operat ive f e m a l e - t o - m a l e t ranssexua l , to ld of the g r a d u a l r e a l i z a t i o n of his t ranssexual ism and his eventua l e f f o r t s to become sex- reassigned. He descr ibed how, b e g i n n i n g at puber ty , he had less and less in c o m m o n w i t h other g i r ls yet because of his pos i t ion as a b i o l o g i c a l f e m a l e , was unable to make f r i e n d s h i p ties w i t h boys; lonel iness and i so la t ion became p r i m a r y themes. Mason then related his exper iences i n seek ing p ro fess iona l help d u r i n g the 1960's. These i n c l u d e d meet ing w i t h : a c h u r c h soc ia l w o r k e r who adv ised h i m to pray ; a psych ia t r i s t who be l ieved he was d e l u s i o n a l ; an endocr ino log is t who said that not ions of sex - reassignment were absurd and that he shou ld get a job; and f i n a l l y , a psych ia t r i s t and gender ident i t y team who d iagnosed h i m as t ranssexual and a c t i v e l y supported his e f f o r t s to hab i l i ta te into the new gender. He reported that the t reatment team's use of the male p ronoun when r e f e r r i n g to h i m , and their r e f e r r i n g to S R S as "cor rect ive surgery," a l l helped h i m in his e f f o r t s to achieve what he terms "self respect." T h o u g h this is a h i g h l y sub ject ive account , the issues raised are impor tan t ones. For example , the d i f f i c u l t i e s of p re -operat i ve cross- l i v i n g , d i s c l o s i n g to f r i e n d s and col leagues, a c c i d e n t a l meetings w i t h past - 31 - acqua in tances , and the shar ing of a c c o m m o d a t i o n when t r a v e l l i n g , are a l l examples of what c o u l d be termed contex tua l issues. E m p i r i c a l work of this type (i.e. that w h i c h focuses on m e d i a t i n g factors w h i c h exist w i t h i n the e n v i r o n m e n t , as we l l as i n t r a p s y c h i c a l l y , and a f f e c t the process of adaptat ion ) appears to be l a c k i n g in the p u b l i s h e d l i te ra tu re . T h i s project has at tempted to address this by v i e w i n g the i n d i v i d u a l not as an isolated p h e n o m e n o n , but rather , as one embedded w i t h i n a context . T h e " E c o l o g i c a l - Systems M o d e l " w h i c h was chosen as a gu ide fo r the c l a s s i f i c a t i o n of these factors , emphas i zed the i n t e r a c t i o n of the i n d i v i d u a l and s u r r o u n d i n g systems. It p r o v i d e d a system of c l a s s i f i c a t i o n w h i c h c lear l y h igh l i gh ts the e n v i r o n m e n t a l i n f l u e n c e s a c t i n g upon the i n d i v i d u a l . E x t e n d i n g the work of Y a r d l e y (1976), Oles (1977), Mason (1980), L c v i n c and S h u m a k e r (1978), the study focused on the s p e c i f i c i n c i d e n t s , events , a t t i tudes , etc., o c c u r r i n g both pre- and post opera t i ve 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 operat i ve role ad justment . The case study approach a l l o w e d for a comprehens ive s tudy of an i n d i v i d u a l , hypotheses generat ion for test ing w i t h others in the p o p u l a t i o n , and a s ta r t ing point to construct and e n r i c h theory. U l t i m a t e l y it is this theory w h i c h w i l l guide c l i n i c i a n s in the i r attempts to impact most pos i t i ve l y on the l ives of t ranssexual people. -32- C H A P T E R III M E T H O D O L O G Y T h e nature of this study has requ i red the use of q u a l i t a t i v e and case study methods. T h e data co l lec t ion has focused h e a v i l y on s e m i - s t r u c t u r e d in te rv iews (w i th both ret rospect ive and cur rent foc i ) in c o n j u n c t i o n w i t h s t a n d a r d i z e d inst ruments : T h e M in n e so ta M u l t i p h a s i c Persona l i t y Inventory ( H a t h a w a y and M c K i n l e y , 1967), the F a m i l y Assessment Measure ( S k i n n e r , S te inhauer & Santa - B a r b a r a , 1984), and the Soc ia l Support Ques t ionna i re (Sarason, L e v i n e , Basham & Sarason , 1983). T h e data analys is , 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 techn ique , has resulted in a c l a s s i f i c a t i o n system based on an eco log ica l model of i n t e r a c t i n g systems. T h e c l a s s i f i c a t i o n system was then subjected to f u r t h e r ana lys i s so as to establ ish a d i s t r i b u t i o n d i s p l a y i n g the c r i t i c a l i nc idents a c c o r d i n g to their perce ived levels of 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: "shal l our uni ts of ana lys i s in the study of pe rsona l i t y be d e r i v e d f r o m general psycho log ica l concepts or f r o m l ives as a c t u a l l y l i ved?" (p. 409). A l l p o r t goes on to descr ibe t r a d i t i o n a l methods as " h o r i z o n t a l " (across people). He uses the term "morphogen ic" or " v e r t i c a l " to descr ibe those methods w h i c h focus on the i n d i v i d u a l and the u n d e r s t a n d i n g of one person rather than many . He chal lenges researchers to ask the quest ion : "Do the h o r i z o n t a l d imens ions (psycholog ica l laws) have true s i g n i f i c a n c e to the i n d i v i d u a l ? " A s an example , he uses the h y p o t h e t i c a l ' B i l l : ' " . . . i f so, how arc they pat terned together to compr ise the ' B i l l i a n ' q u a l i t y of B i l l . Ideal ly research shou ld exp lore both h o r i z o n t a l and ve r t i ca l d imens ions" (p. 410). - 3 3 - Bogden (1974) echoes s i m i l a r concerns about overemphasis on the results of h o r i z o n t a l methods of research in his defense of the use of a u t o b i o g r a p h y as a research tool : Tha t is, the autob iography adds to theory c o n s t r u c t i o n and diagnoses another v i e w point w h i c h prov ides profess ionals w i t h an o p p o r t u n i t y to e x a m i n e the poss ib i l i t y that they are not d o i n g what they profess to be d o i n g or that they are misrepresent ing those w h o m they c l a i m to be te l l i ng us about . T h i s rea l i t y c o n f r o n t a t i o n cannot help but be p r o d u c t i v e , (p. 4) Bogden (1974) has raised two issues w h i c h u n d e r l i e this s tudy . The f i rs t issue quest ions 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 of general psycho log ica l laws obta ined by " h o r i z o n t a l " methods of study. T h e second issue raised is that of ' theory cons t ruc t ion . ' Y i n (1984), in his book Case Study Research states that: Survey research rel ies on ' s t a t i s t i c a l ' g e n e r a l i z a t i o n , whereas case studies (as w i t h exper iments) 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 genera l i za t ion , the invest igator is s t r i v i n g to general ize a p a r t i c u l a r set of results to some broader theory , (p. 39) T h e cho ice of the case study as the p re fe r red research design for this i nves t iga t ion was based on the two above ment ioned issues. A s the rev iew of the l i te ra tu re revea led , there is c u r r e n t l y l i t t le e m p i r i c a l data and even less theory in the area of post operat ive t ranssexual adjustment . In a d d i t i o n to th is , the ex i s t ing research demonstrates what cou ld be in terpreted as an overemphas is on h o r i z o n t a l methods of s tudy in the area. F o r these reasons, more research f o c u s i n g on post operat i ve ad justment is needed. The case study method , w i t h its 'morphogen ic ' focus is an appropr ia te and p r o d u c t i v e method w i t h w h i c h to conduct 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 a television interview with Christine Jorgenson, a post operative male transsexual. Realizing that sex- reassignment was possible, she approached her family physician about the procedure. He recommended that she contact the Johns Hopkins Clinic where sex- - 35 - reassignment was c a r r i e d out. L o g i s t i c a l and f i n a n c i a l cons idera t ions eventua l l y p r e c l u d e d entry into the Johns H o p k i n s p rogram. A p p r o x i m a t e l y three years later , h a v i n g completed t rade school and success fu l l y l aunched her career , the subject approached the p las t i c surgeon who had o r i g i n a l l y operated on her c l e f t palate and c l e f t l i p . H e r e f e r r e d her to the C l a r k e Inst i tute of P s y c h i a t r y in Toronto . A p p o i n t m e n t s at the C l a r k e Inst i tute were secured in the f a l l of 1971. By this t ime the subject had d isc losed her desire for sex - reass ignment to her f a m i l y . She also had begun c r o s s - l i v i n g e x c l u s i v e l y d u r i n g this pe r iod . T w o years later she was s u r g i c a l l y reassigned. I m m e d i a t e l y a f te r surgery the subject moved to V a n c o u v e r where she began w o r k i n g in a large salon. S ince then she has l i v e d in V a n c o u v e r , w i t h the except ion of a three month per iod ( in the f i r s t year) in w h i c h she moved to R c g i n a and l i v e d w i t h her mother . T h i s was af ter the b r e a k - u p of a r e l a t i o n s h i p . In V a n c o u v e r her career has progressed. She has both managed and owned salons. Between 1979 and 1982, however , she s u f f e r e d several per iods of depress ion. There was also one su ic ide attempt d u r i n g this t ime. T h e instances of depress ion have not recur red in the last f i v e years. T h e basis of the depression is somewhat specu la t i ve at this t ime, but appears at least p a r t i a l l y re lated to work pressures c o m b i n e d w i t h re la t ionsh ip d i f f i c u l t i e s . T h e subject reports be ing stable and happy in her present s i t u a t i o n . She enjoys w a r m re lat ions w i t h a l l members of her i m m e d i a t e f a m i l y who express a p p r o v a l and acceptance of her. She m a i n t a i n s a network of m e a n i n g f u l and s u p p o r t i v e f r i e n d s h i p s . It appears that the subject has success fu l l y in tegrated into the post operat i ve role. - 36 - T h e Case S t u d y Invest igator A c o m m o n fac to r in a l l case studies is that the q u a l i t y of the study u l t i - mate ly rests on the expert ise of the case study invest igator in c o l l e c t i n g the data : T h i s is because the data co l lec t ion procedures are not r o u t i n i z e d . In labora to ry exper iments or in surveys , fo r instance , the data c o l l e c t i o n phase of a research project can be la rge ly , i f not w h o l l y , conducted by a research assistant. T h e assistant's goal is to ca r r y out the data c o l l e c t i o n a c t i v i t i e s w i t h a "• m i n i m u m of d i s c r e t i o n a r y behav io r , and in this sense the a c t i v i t y is r o u t i n i z e d — a n d bor ing . There is no such p a r a l l e l in c o n d u c t i n g case studies ( Y i n 1984; p. 56). Y i n goes on to suggest a l ist of sk i l l s requ i red by the case study invest igator : A person shou ld be able to ask good quest ions—and to in terpret the answers. A person shou ld be a good " l istener" and not be t rapped by his or her own ideologies or preconcept ions . A person shou ld be adapt i ve and f l e x i b l e , so that newly encountered s i tuat ions can be seen as oppor tun i t ies , not threats. A person must have a f i r m grasp of the issues be ing s t u d i e d , whether this is a theore t i ca l or p o l i c y o r i e n t a t i o n , even in an e x p l o r a t o r y mode. Such a grasp reduces the re levant events and i n f o r m a t i o n to be sought to manageable propor t ions . A person shou ld be unbiased by p reconce ived not ions , i n c l u d i n g those d e r i v e d f r o m theory. T h u s , a person should be sensi t ive and responsive to c o n t r a d i c t o r y ev idence, (p. 56-57). - 37 - The case study invest igator fo r this project has rece ived graduate level t r a i n i n g i n c o u n s e l l i n g psychology . A s a result of this t r a i n i n g , he has an acceptable leve l of competency at the sk i l l s of l i s t e n i n g and ques t ion ing w h i c h Y i n (1984) h igh l i gh ts as impor tan t . In a d d i t i o n , he has s tud ied ex tens i ve l y in the area of t ranssexua l i sm and gender d y s p h o r i c behav io r and has been able to demonstrate his k n o w l e d g e of the area w i t h col leagues, superv isors and p rac t i t i oners in the f i e l d . The Serai-Structured Interview T h e s e m i - s t r u c t u r e d i n t e r v i e w at tempted to d r a w f r o m both the u n s t r u c t u r e d and s t ruc tured fo rms of the research i n t e r v i e w . R a t h e r than using st r ic t p rotoco l as in the s t ruc tured i n t e r v i e w , the i n t e r v i e w e r used a more general 'gu ide. ' T h e guide c o n t a i n e d a series of quest ions w h i c h served as a general p lan fo r the i n t e r v i e w e r (as opposed to a r i g i d l ist of quest ions w h i c h were to be read verbat im) . In c o m m o n w i t h uns t ruc tu red i n t e r v i e w s , sk i l l s such as r e f l e c t i o n of content and e m o t i o n , p r o b i n g , and open and closed quest ions 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 prepared to (and d id ) generate new quest ions 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 of the in te rv iews . T h e use of a var ie ty of sources of data c o l l e c t i o n served to increase the v a l i d i t y of the results. By i n t e r v i e w i n g not on ly the case subject but also her f a m i l y and selected f r i e n d s , the in te rv iewer was accessing i n f o r m a t i o n w h i c h may have been forgot ten or repressed by the subject. C a u n c l and K a h n (1968) i d e n t i f i e d three reasons for data being inaccessib le through 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 with her common-law husband. In conjunction with the interview data, standardized 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 - 3 9 - P s y c h i a t r i s t who had dealt personal ly w i t h the case subject both pre- and post opera t i ve l y . U n f o r t u n a t e l y this was not possible ; however , the case invest igator m e t - w i t h and i n t e r v i e w e d the coord inato r of the G e n d e r Ident i ty P rogramme. The i n f o r m a t i o n resu l t ing f r o m this meet ing was use fu l in o b t a i n i n g an u n d e r s t a n d i n g of general c l i n i c a l t rends i n w o r k i n g w i t h gender d y s p h o r i c i n d i v i d u a l s . It also suggested issues to be exp lo red in later i n te rv iews 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 Inst i tute released two MMPI p r o f i l e s (one a d m i n i s t e r e d two years p r e - o p e r a t i v c l y [1971] and one a d m i n i s t e r e d two years post opera t i ve l y [1975]) and a b r ie f case s u m m a r y . The C l a r k e Inst i tute of P s y c h i a t r y was not prepared to release the ent i re f i l e on the case subject . 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 cur rent p r o f i l e , a l l owed for a compar i son of scores over a per iod of a p p r o x i m a t e l y s ixteen years. The case s u m m a r y suggested areas to be exp lored in the in te rv iews w i t h the case subject. T h e second i n t e r v i e w w i t h the case subject focused on the t ime f r o m the dec is ion to seek t reatment to the t ime of surgery. I n f o r m a t i o n regard ing her percept ions of the assessment and t reatment process was so l i c i ted . In a d d i t i o n , her memories r e g a r d i n g her react ions and the react ions of s i g n i f i c a n t persons in her l i f e was requested. T h e t h i r d i n t e r v i e w w i t h the subject centered on percept ions of f a m i l y l i f e . T h o u g h i n c l u d i n g i n f o r m a t i o n f r o m earl iest reco l lect ions f o r w a r d , spec ia l focus was p laced on how the f a m i l y helped and/or h indered —or i f they had an e f f e c t - on ad justment to the new gender role. T h e f o l l o w i n g in te rv iews were w i t h the mother and brother . Quest ions were focused in the areas of : f a m i l y re la t ionsh ips , soc ia l re la t ionsh ips , work and school f u n c t i o n i n g , f r o m the past, up to the present. Both the mother and the brother (and at later t ime, the father ) 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 were encouraged to g ive expression to their own exper ience of be ing a witness to this - 40 - process as w e l l as thei r observat ions of its e f f e c t on the subject and 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 focused on ' r o m a n t i c ' l i f e . Data in this area were e l i c i t e d fo r both p re -operat i ve and post operat i ve t ime per iods. In a d d i t i o n , quest ions focused on both heterosexual and homosexua l exper iences. Cons is tent w i t h the research f i n d i n g s in the l i te ra tu re , the m a j o r i t y of romant ic exper iences had occur red post operat i ve ly . T h i s top ic was g i ven spec ia l a t tent ion ( a p p r o x i m a t e l y three and o n e - h a l f hours of i n t e r v i e w t ime) because p r i o r research suggested that romance is an area of ongo ing d i f f i c u l t y fo r many post operat ive i n d i v i d u a l s (Hast ings , 1978) and hence it was thought , mer i ted as much data c o l l e c t i o n as possible. A s in other in te rv iews , the i n d i v i d u a l ' s subject ive exper ience in this area was focused upon ( through the e l i c i t i n g of 'stories') in c o n j u n c t i o n w i t h concrete events. T h e f i f t h i n t e r v i e w w i t h the subject focused on percept ions of f r i e n d s and peer group. T h i s i n c l u d e d react ions to d isc losure , d u r a t i o n and number of f r i e n d s h i p s , fee l ings of be long ing versus i s o l a t i o n , changes in the percept ions of f r i e n d s over t ime, such as acceptance, re jec t ion , etc.. In terv iews w i t h three f r i e n d s of long s tand ing and the case subject's now c o m m o n - l a w husband ( c o - h a b i t a t i o n began d u r i n g the data c o l l e c t i o n per iod) were done th roughout the i n t e r v i e w p e r i o d , as t imes cou ld be a r ranged . These i n t e r v i e w s served to cor roborate i n f o r m a t i o n f r o m the case subject as wel l as p r o v i d i n g new i n f o r m a t i o n to be noted and exp lo red . In a d d i t i o n , these i n d i v i d u a l s were asked for their percept ions of how the subject in quest ion has adjusted to the new role (e.g. soc ia l l y , sexua l l y , in re la t ion to f a m i l y etc.). T h e s i x th i n t e r v i e w w i t h the case subject focused on the t ime f r o m S R S to the present. 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 ready o b t a i n e d , it focused on issues of role adapta t ion and sa t i s fac t ion post opera t i ve l y . The seventh - 41 - i n t e r v i e w was used as a general s u m m a r y and d iscuss ion of the impact of this process (the data co l lec t ion ) on the case subject. 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 Source 1. Case Subject (interview #1) 2. Visit to Clarke Institute of Psychiatry 3. Case subject (interview #2) 4. Interview with Mother Type of Data 5. Interview with Brother 6. Case Subject (interview #3) 7. MMPI.SSQ and F A M (case subject) 8. F A M (family members) 9. Case subject (interview # 4 ) Interview data Case records interview data (specific to subject and general background) past M M P I Profile Interview data Interview data Time Focus past-present past past past-present Interview data past-present Interview data past-present Test data Test data Interview data present present past-present Target Information -factual data -general life story -medical history -employment history -educational history -demographic information, -clinical information -background information regarding transsexualism -events from time of seeking treatment to surgery -reaction of family, friends and professional community -emotional state during this time -helping/hindering factors -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 -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 -family life from childhood to adult family relations -role of family members in facilitating/ hindering adjustment -effect of SRS on relationships with family members -psychological functioning -social support measurement -family functioning -family functioning -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 OF D A T A C O L L E C T I O N (continued) Source Type of Data Time Focus 10. Interview Interview data past-present with Father 11. Case Subject (interview #5) 12. Peer group 13. Case Subject (interview #6 14. Case subject (interview #7) Interview data Interview data Interview data Interview data past-present past-present past-present past-present Target Information -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 -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 -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 -assessment of surgical success -issues regarding assimilation into community as a woman -summary of interview process -concluding remarks What emerged f r o m the in te rv iews was a series of sub ject ive accounts of the process of th is person's l i f e . F r o m each in te rv iewee , a 's tory ' was e l i c i t e d , focus ing on e n v i r o n m e n t a l events and the case subject's react ion to and impact on that env i ronment . Statements o f behav io r , of f e e l i n g , and of thought were probed for throughout these accounts . I n te rv iew d a t a , c o m i n g f r o m other than the subject hersel f served not only 10 cor roborate her statements but also to generate f u r t h e r quest ions and arenas to be exp lo red . - 43 - D a t a A n a l y s i s Once complete , the i n t e r v i e w data were reduced to a series of inc idents w h i c h were then c l a s s i f i e d in to Conger 's three levels of ana lys is . T h e p r i m a r y c r i t e r i o n fo r an i n c i d e n t to be cons idered as ' s i g n i f i c a n t ' was that the occurrence of this i n c i d e n t led to an observable change or result . In e f f e c t , this requ i red that a l l i n c i d e n t s had to have resulted in a b e h a v i o r a l outcome (or at least to have had an outcome w h i c h had a b e h a v i o r a l component to it). T h o u g h cogn i t i ve and a f f e c t i v e e f fec ts of inc idents were noted, a conscious dec is ion was made to restr ict 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 b e h a v i o r a l requ i rement . T h i s was done so as to a v o i d the ' h y p o t h e s i z i n g ' by the in te rv iewee , ( w h i c h F l a n a g a n [1954] warns against i n c o n d u c t i n g a " C r i t i c a l Inc ident" study) . T h e c l a s s i f i c a t i o n leve l , labeled " C o m m u n i t y " was the most d isparate of the three levels , in terms of the m o t i v a t i n g sources of inc idents . It also conta ined the greatest number of inc idents . To a d d c l a r i t y to this leve l , it was f u r t h e r d i v i d e d into sub-categor ies 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 Conger , 1981) i n v o l v e d w i t h the inc idents (sec T a b l e 3.1). T A B L E 3.1 A N E X A M P L E O F T H E C O M M U N I T Y C L A S S I F I C A T I O N C O M M U N I T Y Inc ident Resu l t - m e d i c a l system - e d u c a t i o n a l system - f r i e n d s T h e nature of the sub-categor ies came out of the data i tsel f rather than any a priori system (i.e. inc idents i n v o l v i n g teachers were grouped into a sub-category ent i t led " E d u c a t i o n a l " , inc idents i n v o l v i n g work exper iences f o r m e d the sub- category " V o c a t i o n a l " , etc.). - 44 - T h e use of the s t a n d a r d i z e d ins t ruments , each r e f l e c t i n g one of the levels of data ana lys is (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 how the subject c u r r e n t l y f u n c t i o n s . These results served to complement the in te rv iew data and p r o v i d e d an o p p o r t u n i t y to examine the convergence and d ivergence of i n f o r m a t i o n generated f r o m the d i f f e r e n t sources. T h e pre - and post S R S , Minnesota Multiphasic Personality Inventory p ro f i l es demonst rated what persona l i t y changes have taken place over t ime ( i n d i v i d u a l level o f analys is ) . F r o m the h i s t o r i c a l and retrospect ive da ta , case records, test scores and i n t e r v i e w s , the study at tempted to show the manner in w h i c h the case subject , p r i o r to and at the t ime of S R S , was f u n c t i o n i n g . The data c o l l e c t i o n , f o c u s i n g on cur rent i n f o r m a t i o n , obta ined f r o m test scores and i n t e r v i e w s , demonstrated how the subject f u n c t i o n s today. The ana lys i s of the c r i t i c a l inc idents and thei r results, ob ta ined by the use of the " C r i t i c a l Inc ident T e c h n i q u e " attempted to answer the i n i t i a l quest ion of 'what ' fac tors have been s i g n i f i c a n t . F r o m responses w i t h i n the i n t e r v i e w s , wc at tempted to answer ' w h y ' these factors 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 i n t e r v i e w e d . In a d d i t i o n , a c l a s s i f i c a t i o n analys is of the ' c r i t i c a l inc idents ' was u n d e r t a k e n in w h i c h the case subject ordered the inc idents on a s ix point scale v a r y i n g f r o m 'most s i g n i f i c a n t ' to 'least s i g n i f i c a n t ' . The same process was u n d e r t a k e n i n d e p e n d e n t l y by the case invest igator . The c o r r e l a t i o n between the two independent r a n k i n g s was then ca l cu la ted so as to ascer ta in the level of agreement between invest igator and subject on the quest ion of re la t i ve impor tance of the inc idents . - 45 - The Critical Incident Technique Woolsey (1985) argues that a sch ism exists between researchers and p rac t i t i oners i n c o u n s e l l i n g psychology . She suggests that this is at least in part the result o f the disuse of research methodologies w h i c h w o u l d have re levance to, and use the s k i l l s of the p rac t i t ioners (as we l l as of the researchers) . She goes on to state: T h u s , it seems i m p e r a t i v e to exp lore new methodologies i n research, not on ly to better address the research quest ion , but to resolve the v a l u c - incongruence between counse l l i ng theories and research parad igms , so that counsel lors w i l l be enabled to f u l l y develop thei r research potent ia 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 va lue - congruent as wel l as p rac t i ce e f f e c t i v e . C o u n s e l l o r t r a i n i n g i n the s k i l l s of i n t e r v i e w i n g , e m p a t h i c l i s t e n i n g , p a r t i c i p a n t obse rva t ion , v i v i d q u a l i t a t i v e d e s c r i p t i o n and the ana lys is of i n t r a - p e r s o n a l and in te r -persona l patterns are a l l re levant to q u a l i t a t i v e , n a t u r a l i s t i c , phenomeno log ica l and eco log ica 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 techn ique as an example of a method of research we l l su i ted to be used by counsel lors . It meets the requi rements of acceptab le v a l i d i t y and r e l i a b i l i t y w h i l e r e m a i n i n g congruent w i t h h u m a n i s t i c values. In a d d i t i o n , the s k i l l s requ i red to execute the techn ique complement the t r a i n i n g and exper ience of most counsel lors . It is a techn ique appropr ia te to e x p l o r a t o r y research (Woolsey, 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 in 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 study: (1) d e t e r m i n i n g the o v e r a l l a i m of the a c t i v i t y under s tudy ( in this case, the o v e r a l l a i m was to s tudy the process of adapta t ion to the gender reassigned role); (2) f o r m u l a t i n g plans and s p e c i f i c a t i o n s for c o l l e c t i n g i n f o r m a t i o n about the - 4 6 - a c t i v i t y s tud ied ( in this study f a m i l y , f r i e n d s and the i n d i v i d u a l hersel f , were g i ven ins t ruc t ions to report on behav iors , thoughts and fee l ings w h i c h have had an observable e f f e c t on the case subject's process of post operat i ve role adapta t ion ) ; (3) c o l l e c t i o n of the i n f o r m a t i o n by the process of i n t e r v i e w a n d case record a n a l y s i s ; (4) ana lys is of the d a t a ; (5) in te rp re ta t ion and r e p o r t i n g of the data . Andersson and N i l s s o n (1964) in the i r study of r e l i a b i l i t y and v a l i d i t y of the techn ique , c o n c l u d e d that it adequate ly assessed the content d o m a i n and that other methods of assessment when a p p l i e d , d i d not add new i n f o r m a t i o n . In a d d i t i o n they f o u n d that d i f f e r e n t in te rv iewers on ly m a r g i n a l l y a f f e c t e d the number and d i s t r i b u t i o n of the c r i t i c a l inc idents . T h e y c o n c l u d e d that the method a l l o w e d f o r the co l lec t ion of data w h i c h was both re l iab le and v a l i d . The C r i t i c a l Inc ident Sca le F o l l o w i n g F lanagan 's (1954) gu ide l ines for c o n d u c t i n g a c r i t i c a l i nc ident s tudy , 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 members of her f a m i l y , and s p e c i f i c f r i e n d s of long s tand ing . It was d u r i n g these i n t e r v i e w s that the c r i t i c a l inc idents were revealed. A l l inc idents descr ibed by other than the case subject were discussed w i t h her d u r i n g later in te rv iews . It was a requ i rement , fo r the i n c i d e n t to be cons idered 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 facts of the i n c i d e n t and of its result. A scale was deve loped so as to a l l o w for a rater(s), in th is case the case subject and the case invest igator , 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 30 inc idents . T h e s i x - l e v e l scale was designed so as to fo rce a "normal d i s t r i b u t i o n " of inc idents . To accompl i sh this each level was on ly a l l owed a s p e c i f i e d number of inc idents (Leve l One , one i n c i d e n t ; L e v e l T w o , f o u r inc idents ; L e v e l Th ree , 10 inc idents ; L e v e l F o u r , 10 inc idents ; L e v e l F i v e , f o u r inc idents ; L e v e l S i x , one inc ident ) . - 47 - F o r any i n c i d e n t to be cons idered ' c r i t i c a l ' i t had to have had some type of observable result . T h i s d e f i n e d the m i n i m a l requ i rement of L e v e l One: that the i n c i d e n t resulted in a s ingle consequence or behav ior . T h e second leve l s p e c i f i e d a series or group of consequences/behaviors as a result of the i n c i d e n t . L e v e l Three added the d i m e n s i o n of a t t i t u d i n a l change to the basic b e h a v i o r a l requ i rements and L e v e l F o u r extended the b e h a v i o r a l and a t t i t u d i n a l components over a greater per iod of t ime (greater than three months). L e v e l F i v e i n c o r p o r a t e d observable consequences in others as a result of the changes fo r the case subject . L e v e l Six m a r k e d the s ingle most s i g n i f i c a n t inc ident as d e f i n e d by its long term or permanent r a m i f i c a t i o n s on behav ior and at t i tude change fo r the case subject and others i n v o l v e d in her l i f e . S t a n d a r d i z e d Instruments Th ree s t a n d a r d i z e d inst ruments were used i n this study: the Minnesota Multiphasic Personality Inventory, the Family Assessment Measure and the Social Support Questionnaire. The Minnesota Multiphasic Personality Inventory was chosen p r i m a r i l y because it a l l o w e d the researcher to compare the cur rent p r o f i l e w i t h past p r o f i l e s of the same inst rument . T h i s resulted in be ing able to measure change in psycho log ica l adjustment (as measured by the MMPI) over some s ixteen years. The Family Assessment Measure attempts to integrate both systemic and nonsystemic theories of psycho log ica l adjustment w i t h i n the f a m i l y . It also focuses on the process of f a m i l y in te rac t ion rather than on f a m i l y s t ructure ( w h i c h was of d o u b t f u l appropr iateness in v iew of the ages of the c h i l d r e n , and of the i r separate domic i les ) . T h e Family Assessment Measure was chosen f o r these reasons. The Social Support Questionnaire tested the subject's percept ion of the adequacy of her soc ia l support . A number of ins t ruments in this top ic area were r e v i e w e d , - 48 - however , the Social Support Questionnaire was chosen here fo r the types of support it measures, as we l l as fo r its reported v a l i d i t y and r e l i a b i l i t y . 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 Inventory T h e Minnesota Multiphasic Personality Inventory ( H a t h a w a y and M c K i n l e y , 1967) f i r s t appeared in 1940 and since that t ime has become the most ex tens ive ly researched p a p e r - a n d - p e n c i l index of psycho log ica l ad justment in existence ( H o p k i n s and Stan ley , 1981). The MMPI consists of ten " c l i n i c a l scales" and three " v a l i d i t y scales." The ten c l i n i c a l scales are as fo l lows : 1. Hs: H y p o c h o n d r i a s i s 2. D: Depress ion 3. H y : H y s t e r i a 4. P d : P s y c h o p a t h i c dev iate 5. M f : M a s c u l i n i t y - f e m i n i n i t y 6. Pa : P a r a n o i a 7. Pt: Psychasthen ia 8. Sc: S c h i z o p h r e n i a 9. M a : H y p o m a n i a 0. S i : Soc ia l In t rovers ion The three v a l i d i t y scales consist of: (L) L i e Score: C a l c u l a t e d f r o m a group of items w h i c h w o u l d appear to put the examinee in a f a v o u r a b l e l ight but in rea l i t y arc u n l i k e l y to be answered in the scored d i r e c t i o n i f the examinee is a n s w e r i n g t r u t h f u l l y . (F) V a l i d i t y Score: C a l c u l a t e d f r o m a set of i tems w h i c h though d e s c r i b i n g undes i rab le behav io r arc not f r e q u e n t l y answered in the scored d i r e c t i o n by any s t a n d a r d i z a t i o n group. A s a set they adhere to no pattern of a b n o r m a l i t y or psychopathology . A h igh F score may i n d i c a t e scor ing er rors , carelessness in the examinee's responses or de l ibera te m a l i n g e r i n g ( f a k i n g bad). - 4 9 - ( K ) C o r r e c t i o n Score: The K score is a measure of test t a k i n g a t t i tude . A h igh K score may i n d i c a t e defensiveness and/or an attempt to appear in a f a v o u r a b l e l ight . A low K score may be i n d i c a t i v e of excessive self c r i t i c i s m or m a l i n g e r i n g (Anas tas i , 1982). T h e MMPI consists of 550 statements to w h i c h the subject responds w i t h "true" " fa lse" or "cannot say". Used p r i m a r i l y fo r the process o f d i f f e r e n t i a l d iagnos is , reports of test scores on this ins t rument are not u n c o m m o n in the research on t ranssexua l i sm. T h o u g h there is cons iderab le ev idence to suggest that e levat ion on the c l i n i c a l scales is i n d i c a t i v e of psycho log ica l d i s t u r b a n c e ( A n a s t a s i , 1982), research in the area of t ranssexual ism has not demonst rated a consistent or t y p i c a l t ranssexual p r o f i l e (Wcatherhead, et a l . , 1978). The ins t rument has also not proved to be re l iab le in terms of its a b i l i t y to predic t post operat i ve ad justment (L. C l e m m e n s o n , personal c o m m u n i c a t i o n , F e b r u a r y , 1986). T h e MMPI was used in this project as a measure of both psycho log ica l ad justment and of change in adjustment over t ime. Test scores f r o m 1971 (pre- operat ive) 1975 (post operat ive) and 1987 (post operat ive) were in te rp re ted . T h i s a l l o w e d fo r d i rec t compar i son of f u n c t i o n i n g , as measured by this ins t rument . T h e i n d i v i d u a l f o r m of 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 and scored in 1971 and 1975 by the s t a f f of the C l a r k e Inst i tute of P s y c h i a t r y and by the case study invest igator fo r the 1987 a d m i n i s t r a t i o n . A n outs ide psycholog is t , (Dr . 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 ) expert in the area of MMPI i n t e r p r e t a t i o n , was enl is ted fo r the task of i n t e r p r e t i n g a l l three of the p r o f i l e s fo r this project. H i s d iscuss ion of the p ro f i l es was a u d i o taped for later rev iew. T h e p r i m a r y reference for i n te rp re ta t ion , used by Dr . T o m b a u g h , was: The MMPI: Clinical Assessment and Automated Interpretation. (1974). - 50 - The Family Assessment Measure T h e Family Assessment Measure (Sk inner , S te inhauer & S a n t a - B a r b a r a , 1984) deve loped at the A d d i c t i o n Research F o u n d a t i o n (Toronto , O n t a r i o ) is a se l f - repor t ins t rument w h i c h attempts to measure elements of f a m i l y s t rength and weakness. T h e basic d imens ions assessed by the FAM are: task a c c o m p l i s h m e n t , 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 express ion, i n v o l v e m e n t , c o n t r o l , values and norms. T h e assessment of these d imens ions is a c c o m p l i s h e d th rough three separate scales: the G e n e r a l Scale , D y a d i c R e l a t i o n s h i p Scale and Sel f R a t i n g Scale. E a c h scale a l lows fo r a d i f f e r e n t perspect ive of 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 te inhauer & S a n t a - B a r b a r a , 1983). The FAM is based on a "Process M o d e l " w h i c h emphasizes the d y n a m i c in te ract ions of major aspects of f a m i l y f u n c t i o n i n g as we l l as the i n t e r p l a y between the i n d i v i d u a l and the group: the i n t r a p s y c h i c and the in te rpersona l . T h e focus is one of process rather than s t ructure . (Ste inhauer , 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 in the T o r o n t o area) are descr ibed in S k i n n e r et a l . , 1983. D e m o g r a p h i c i n f o r m a t i o n , i n c l u d i n g age, sex, length of c o h a b i t a t i o n , number of c h i l d r e n , educat ion leve l , income, etc., demonstrates 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 for the o v e r a l l scales fo r adul ts range f r o m .89 to .93 and fo r c h i l d r e n , f r o m .86 to .94. R e l i a b i l i t y rat ings fo r each of the subscales are also g iven fo r both adul ts and c h i l d r e n . T h e range for adul ts is f r o m a low of .39 (Self R a t i n g : C o n t r o l ) to a high of .87 (Genera l Scale: Soc ia l D e s i r a b i l i t y ) . The range for subscale r e l i a b i l i t y fo r c h i l d r e n is .27 (Self R a t i n g : Ro le Per fo rmance ) to .77 ( C o m m u n i c a t i o n : D y a d i c R e l a t i o n s h i p s ) . R e l i a b i l i t y is a f f e c t e d by the number of i tems, and the decrease in subscale r e l i a b i l i t y , to a degree, is to be expected on these b r i e f e r subscales ( S k i n n e r , et a l . 1984). T h e p r i m a r y scale r e l i a b i l i t i e s can be cons idered qui te robust. A m u l t i v a r i a t e compar i son of p rob lem and n o n p r o b l e m f a m i l i e s is also - 51 - repor ted . T h e results supported the FAM 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 between ' p r o b l e m ' and ' n o n p r o b l e m ' f a m i l i e s (Sk inner , et a l . 1984). T h e deve lopment of the constructs (i.e. of the Process M o d e l ) upon w h i c h the FAM is based are deta i led in Ste inhauer et a l . (1984). A t present it is reported that research in to ex te rna l v a l i d a t i o n of the constructs is ongo ing . In a d d i t i o n f u r t h e r research e x a m i n i n g its concur rent v a l i d i t y ( co r re la t ion w i t h other f a m i l y ins t ruments ) is noted, as is research into its c l i n i c a l and p r e d i c t i v e v a l i d i t y ( 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 inst rument . D i r e c t i o n s for comple t ion of the scales are on the f r o n t cover of the cor respond ing quest ion booklet . With the case subject , the invest igator rev iewed the purpose of the FAM and general gu ide l ines f o r c o m p l e t i o n . He remained present w h i l e the case subject completed the quest ionna i res . T h e other f a m i l y members (who do not l i ve in the same c i t ies as each other or as the case invest igator ) were contacted by te lephone (permiss ion had been granted fo r this at a pr io r meeting). D u r i n g this c o n v e r s a t i o n , the invest igator r e v i e w e d the purpose of the test and gu ide l ines for c o m p l e t i o n . The booklets and quest ion/answer sheets, w i t h an at tached letter r e i t e r a t i n g ins t ruct ions and ra t iona le , were then m a i l e d to each of the f a m i l y members , who completed the tests and m a i l e d them back to the case invest igator . E a c h scale consists of e i ther 42 or 50 statements to w h i c h the test - taker answers w i t h "strongly agree," "agree," "disagree," or "strongly disagree." A s the examinee marks the answer sheet, the marks are t r a n s f e r r e d (carbon copy) to at tached scorer 's sheets. F r o m this the scorer can ca lcu la te raw scores, and then t r a n s f o r m the raw scores to s tandard scores (tables p rov ided ) . P r o f i l e s arc p r o v i d e d fo r g raph ic d i s p l a y and compar i son , as arc gu ide l ines fo r in te rp re ta t ion of the scores. - 52 - T h e FAM was chosen f o r this project not on ly fo r its reported r e l i a b i l i t y , v a l i d i t y and ease of a d m i n i s t r a t i o n , but also for its focus on process rather than s t ruc ture and its at tempt to integrate systems theory w i t h i n d i v i d u a l psychopatho logy . T h e emphasis it places on the " in te r face between the i n d i v i d u a l subsystems and the f a m i l y system" (Ste inhauer , et al . ,1984, p. 78) was thought to be ex t remely a p p r o p r i a t e to this case study. T h e case subject was asked to complete a l l of the quest ionna i res f r o m the po int of v i e w of how the f a m i l y c u r r e n t l y f u n c t i o n s (keep ing in m i n d their separate domic i les ) . T h e subject completed three D y a d i c R e l a t i o n s h i p Scales (i.e. r e l a t i n g to her mother , her fa ther and her brother) . T h e other f a m i l y members were each asked to complete a G e n e r a l Scale and a D y a d i c Scale ( cons ider ing their r e l a t i o n s h i p w i t h the case subject) . T h i s a l l owed for the c o m p a r i s o n of three d i f f e r e n t v iews (note: the father dec l ined to par t i c ipate in this sect ion of data co l lec t ion ) of the f a m i l y f u n c t i o n i n g , as we l l as d i f f e r e n t v iews on the d y a d i c re la t ionsh ips of the case subject w i t h other f a m i l y members. Social Support Questionnaire T h e Social Support Questionnaire (Sarason, L c v i n c , Basham and Sarason, 1983) was used as a measure of adequacy of socia l support . In d i scuss ing issues in the measurement of soc ia l support , Sarason et a l . state that: Regard less of how it is c o n c e p t u a l i z e d , socia l support w o u l d seem to have two basic elements: (a) the percept ion that there is a s u f f i c i e n t number of a v a i l a b l e others to w h o m one can turn in times of need and (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 present ing his v iew of the conceptua l issues i n v o l v e d in the area of socia l support measurement , T a r d y (1985) suggests that there are f i v e basic d imens ions in d e f i n i n g the construct . H e represents these d imens ions as: (a) D i r e c t i o n , (b) 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) Content , (e) N e t w o r k . D i r e c t i o n he sees as being the d i r e c t i o n of the support : e i ther g iven or rece ived . T h e issue is not w h i c h d i r e c t i o n is s tud ied but rather that the d i r e c t i o n is ove r t l y d e l i n e a t e d . D i s p o s i t i o n , l i k e D i r e c t i o n is seen as c o m p r i s i n g two c o m p l i m e n t a r y components : a v a i l a b i l i t y (quant i ty and/or q u a l i t y ) 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 again to two re lated facets of soc ia l support . D e s c r i p t i o n refers o n l y to the existence of supports , w h i l e e v a l u a t i o n refers to the i n d i v i d u a l ' s leve l of sa t i s fac t ion w i t h the support a v a i l a b l e . Research is reported w h i c h looks at these facets i n d i v i d u a l l y and together. Content of soc ia l support is conceptua l i zed by c i t i n g House (1981), who d i s t i n g u i s h e d a m o n g fou r types of support content : e m o t i o n a l , i n s t r u m e n t a l , i n f o r m a t i o n a l and a p p r a i s a l . T h e term N e t w o r k descr ibes the existence of a support network w i thout i m p l y i n g a d i r e c t i o n for the support ( Ta rdy , 1985, p. 188-190). H a v i n g rev iewed a var ie ty of the inst ruments in this a rea , the Social Support Questionnaire {SSQ) was chosen for this study fo r a number of reasons. Inspect ion of the SSQ reveals that it too meets T a r d y ' s basic c r i t e r i a (1985) for c o v e r i n g the range of basic elements of socia l support . The SSQ c l e a r l y states that the D i r e c t i o n of the support be ing discussed is c o m i n g ' to ' the i n d i v i d u a l in quest ion and not f r o m the i n d i v i d u a l . In terms of D i s p o s i t i o n , the ins t rument focuses on a v a i l a b i l i t y rather than on enactment . D e s c r i p t i o n and E v a l u a t i o n arc both ove r t l y measured by the inst rument . Content tends to re fer p r i m a r i l y ( though - 54 - not e x c l u s i v e l y ) to emot iona l support and f i n a l l y , a N e t w o r k of support is measured by the SSQ. In repor t ing a series of projects inves t iga t ing the SSQ, (Sarason, L e v i n e , B a s h a m , and Sarason, 1983) a study of 602 undergraduate u n i v e r s i t y students f o u n d that N scores (number of persons ava i lab le ) had an i n t e r n a l r e l i a b i l i t y c o e f f i c i e n t (between items) of .97 and the co r re la t ion of i tems w i t h the total score ranged f r o m .51 to .79. T h e S scores (sat is fact ion) had an a l p h a c o e f f i c i e n t of .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 tota l score ranged f r o m .48 to .72. T h e test-retcst r e l i a b i l i t y ( for 105 students to w h o m the test was re- admin i s te red ) was .90 ( N scores) and .83 (S scores) over a 4 -week i n t e r v a l . A f u r t h e r s tudy reported s i g n i f i c a n t negat ive cor re la t ions w i t h depress ion . Other studies in this scries corre late the measure w i t h lack of s a t i s f a c t i o n in socia l support and the occur rence of negative l i f e events as we l l s i g n i f i c a n t pos i t ive co r re la t ions ( in female subjects) between N scores and e x t r o v e r s i o n , and negative cor re la t ions ( in female subjects also) between n e u r o t i c i s m scores and S scores. The authors note that on the latter two studies the results fo r men were in the same d i r e c t i o n as for women but were not as strong. T h e c o m b i n a t i o n of construct and concur rent v a l i d i t y , and in te rna l r e l i a b i l i t y , o u t w e i g h the d isadvantage of the ins t rument not h a v i n g an extensive n o r m i n g p o p u l a t i o n . The authors report a range of N scores f r o m 2.92 to 5.46 w i t h a mean of 4.25 and 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 and means are reported on the sample of 602 undergraduate u n i v e r s i t y students. L i k e the FAM, the SSQ is largely s e l f - a d m i n i s t e r e d . T h e researcher rev iewed the ra t iona le and gu ide l ines for c o m p l e t i n g the q u e s t i o n n a i r e w i t h the case subject , and then remained present in the room w h i l e she completed it. The test consisted of 27 items to w h i c h the subject was requ i red to: (a) list the pcrson(s) - 55 - (by i n i t i a l s and re la t ionsh ip ) to w h o m she cou ld tu rn fo r support i n the manner descr ibed by the quest ion , (b) c i r c le the sa t i s fac t ion leve 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 quest ioned (i.e. on a scale of "1 -very d i s s a t i s f i e d " to "6 -very sat is f ied" ) . T h e o v e r a l l N and S scores were ca l cu la ted by t a k i n g the sum of each sect ion ( N and S) and d i v i d i n g by the number of items (27). - 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 to Conger's levels of assessment (individual, family and community). 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). Though the scores showed both obsessive-compulsive and schizoid tendencies, there was no evidence of actual delusions or psychotic reactions. 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). There was also some evidence of interpersonal panic (pattern of scales 7, 8, & 9). -57- Flgure 4.1 7M 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 S.R Hathaway and I ( M> Kin l rv 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 TorTe 7 8 Pt+IK Sc+IK M - 55 - M - SO - 45 - 45 - <0 - 40 - » / > » JO - 30 — 25 - ?5 - 20 - K - frietmi of K K 5 .4 2 X 15 12 1 29 IS 12 « a 14 t l < 27 14 t l 5 » 1} 10 S 25 1) 10 5 24 12 10 5 23 12 9 5 22 t l 9 4 21 It t 4 20 10 i 4 19 10 a 4 ia 9 i 4 17 9 j 3 16 1 6 3 15 S 1 3 14 7 6 3 1] 7 5 3 12 s S 2 It « 4 2 10 s 4 2 9 s 4 2 a 4 3 2 7 4 3 1 t 3 2 t i 3 2 1 i 2 2 1 i 2 1 1 2 1 1 0 1 t 0 0 0 0 ') 0 MALE 3 0 - IS - 29 - ) - 5 - 4 0 - 3 0 - 2 0 - 15 - S O - 45- 5 0 - 4 0 - 15 - 4d 15 - 3 0 - 120 - 0 - IS - 4 0 - 2 0 - torTc Raw Score. 0 8 10 7 23 23 21 45 13 25 25 24 30 _5_ _4_ 10 10 2 12 25 35 35 26 K to be added Raw Score with K - 5 8 - Flgure 4.2 7M 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 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 Lcense ftom The Umverany ot Minnesota Pim*e n the Unflec Su*» ot AmeicJ Minnesota Multiphasic Personality Inventory" anc MMPr are traOemarKs owned by The University ol Minnesota TorTe ' I t K 1 MI+5K 7 8 Pl+IK SC+1K 6 5 - 6 0 - 6 0 - 5! - 5 5 - 5 0 - 5 0 - 4 5 - 4 0 - 3 5 - 3 5 - 30 - / •rattens* K K i 4 3 X IS 17 6 79 ts 1? 6 76 14 11 • 77 14 11 5 76 13 10 5 » 13 10 S 74 17 10 5 73 17 > 5 77 11 9 4 M 11 B 4 70 10 • 4 It 10 6 4 18 9 7 4 17 t 7 3 te 1 t 3 15 I 6 3 14 7 e 3 13 7 5 3 17 1 6 7 II t 4 2 10 s 4 2 • i 4 2 6 » 3 2 7 3 t • i 7 l i i 7 I < 7 ? 1 3 7 1 1 7 1 1 0 I 1 0 0 0 0 0 0 1 7 0 - 11 1 1 0 - 1 » . 1 0 0 - » - 90 « S - 8 0 - ' Ti- n- to-. 6 0 - 3 0 - 45 4 0 - 35 •' J 0 - 7 5 - ; n -. 0 - FEMALE 4 5 - • 5 0 - 5 0 - 4 5 - 4 5 - 4 0 - ts - 4 0 - 4 0 - 35 - 7 0 - 3 5 - 3 5 - 3C - 7 5 - 30 — 2« y 3 0 - 75 - 2 5 - 7 0 - 7 0 / j o - 3 5 - 75 - • 1 5 - X- >5 - 5 - 2 0 - 1 5 - 15 - 1 0 - 45 - 1 5 - 1 0 - 10 - 1 0 - 5 - 1 0 - 0 - 1 0 - 5 — 4 0 - 3 5 - 70 65 60 55- SO- 45 • 40- 3 5 - TorTc Raw Score. ' i > « H>-» 5« 1 _ L A . 1 1 J _ K to be added _1P Raw Score with K Jli 0 Hy P*+4« HI Pi Pl+IK Sc+IK Ml-f 2« S> 1 3 4 8 8 7 8 t O J A 2 Q _ L 7 _ i L t l _ ^ _ 5 _ 2 1 _ l J b - 8 19 19 4 23" 25 24 25 -59 - 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 S.R. Hathaway and ).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 Minnesota Multiphase Personality Inventory" -ir.1 MMPI Irndemams flwned by The University ol Minnesota Raw Score 3 3 18 1 15 21 K to be added _2_ Raw Score with K 10 _7_ 21 23 21 _4_ 19 - 60 - Inspect ion of the 1975 p r o f i l e (two years a f te r surgery) showed several s i g n i f i c a n t changes. The K scale had r isen f r o m a T=41 in the 1971 p r o f i l e to a T=61 in 1975. T h i s level of e levat ion on the K scale, in c o n j u n c t i o n w i t h a low L score (T=52) ra ised some questions. The pat tern of a h igh K and low L scores may have re f lec ted a lack of v a l i d i t y in the p r o f i l e , or it may have s i g n i f i e d an increase in ego strength (i.e. the i n d i v i d u a l was not ' f a k i n g good ' but rather felt good about hersel f ) . T h i s pattern also tends to occur a f te r an i n d i v i d u a l has p a r t i c i p a t e d in psychotherapy . A f t e r rev iew and c o m p a r i s o n w i t h the other p r o f i l e s , this p r o f i l e was accepted as v a l i d (the hypothes is of increased ego st rength was accepted) . Other changes f r o m 1971 i n c l u d e d the decrease in e leva t ion of scale 2 (depression). It was in terpreted that post o p e r a t i v e l y , the case subject was express ing less a n a d o n i a and more pleasure in l i f e . E l e v a t i o n s on scale 4 (T=64) and scale 9 (T=71) were in terpreted as ev idence of a h igh -energy person who holds a ce r ta in sense of anger and who as a result has the potent ia l to 'act out ' in some negat ive way. T h i s h igh energy and inner anger was also ev ident in the 1971 p r o f i l e . It should be noted that the n o n - c l i n i c a l scale 5 had by this t ime, d ropped to 31 (T=70) f r o m 45 (T=97). T a k e n in its ent i re ty , the 1975 p r o f i l e was in te rpre ted as r e f l e c t i n g a p s y c h o l o g i c a l l y ' hea l th ie r ' person than d i d the 1971 p r o f i l e . T h e d r o p of scales 7 and 8 were eva luated as s i g n i f y i n g acceptance, rather than re ject ion of self , and the d rop of scale 2 demonstrated that the subject was a t t a i n i n g more pleasure in l i f e . T h e 1987 p r o f i l e showed on ly scale 5 (a non c l i n i c a l scale) as be ing elevated beyond one s tandard d e v i a t i o n (T=64). S c o r i n g on the "Female" p r o f i l e (since both 75 and 87 are post operat ive p ro f i les ) the e levated M F score was in terpreted as s h o w i n g the case subject as more assert ive and aggressive than the mean of the reference p o p u l a t i o n . T h i s was thought , however , to be qu i te appropr ia te and - 61 - consistent w i t h the role expectat ions of the w o r k i n g woman in our present day society . E v i d e n c e of depression as w e l l as of 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 (hypomania ) on this cur rent p r o f i l e d ropped to w i t h i n one s tandard d e v i a t i o n of the mean. F r o m this , it can be suggested that the 'energy ' ev ident in the p rev ious p r o f i l e s was p robab ly a n x i e t y d r i v e n rather than p h y s i o l o g i c a l l y based. T h e ev idence o f anger (scale 4) present in the 1971 and 1975 p ro f i l es was n o t i c e a b l y decreased i n the 1987 p r o f i l e . T h e cur rent p r o f i l e was seen as be long ing to a p s y c h o l o g i c a l l y ' hea l thy ' i n d i v i d u a l . O v e r a l l , these three p ro f i l es i n d i c a t e d an i n d i v i d u a l who, over a s ix teen year p e r i o d , had become less r i g i d and more f l e x i b l e , less stereotyped in terms of sex role behav io r , s i g n i f i c a n t l y more re laxed , less anx ious and more accept ing of hersel f and capable 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 Measure A l l three fo rms of the Family Assessment Measure (FAM) were a d m i n i s t e r e d to the case subject: The G e n e r a l Scale , The I n d i v i d u a l Scale and The D y a d i c R e l a t i o n s h i p Scale. T h e case subject's mother and brother also completed the G e n e r a l scale and the D y a d i c R e l a t i o n s h i p Scale ( focus ing on thei r re la t ionsh ip w i t h the case subject) . T h e case subject's f a t h e r agreed to be i n t e r v i e w e d but d e c l i n e d to complete the F A M quest ionnai res . T h i s sect ion of data co l lec t ion has a l l o w e d f o r the compar i son of d i f f e r e n t percept ions of f a m i l y f u n c t i o n i n g and of d y a d i c re la t ionsh ips between the subject and her mother , and the subject and her brother . T h o u g h i n f o r m a t i o n f r o m the fa ther w o u l d have been usefu l fo r added c o m p a r i s o n , the re la t ionsh ip w i t h h i m is desc r ibed , but on ly f r o m the point of v iew of the case subject. - 6 2 - Ident i ca l ins t ruc t ions were g iven to each of the i n d i v i d u a l s c o m p l e t i n g the quest ionna i res . T h e one m o d i f i c a t i o n made to the s tandard FAM manua l ins t ruc t ions was necessitated by the separate l i v i n g s i tuat ions of a l l f a m i l y members. E a c h person was ins t ructed to answer the quest ions to the best of their a b i l i t y , f r o m the perspect ive of how 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 . Quest ion #2 ( " F a m i l y dut ies are f a i r l y shared") was used as an example of a quest ion w h i c h might be c o n f u s i n g because of the i r separate l i v i n g s i tuat ions . It was suggested to each f a m i l y member that the term 'dut ies ' c o u l d s t i l l a p p l y , but not in the same sense (e.g. household duties) that it w o u l d have when they were a l l l i v i n g together. A f t e r d iscuss ion w i t h each of the i n d i v i d u a l s , it appeared that there were 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 and re la t ing the quest ions to thei r cu r rent s i t u a t i o n . Once the quest ionnai res were comple ted , responses were scored and then t r a n s f o r m e d in to s tandard scores as per d i rec t ions in the in te rp re ta t ion guide. The mean f o r s tandard scores is 50 and the s tandard d e v i a t i o n is 10. In terpretat ion of the p r o f i l e s was completed by the case invest igator . For the G e n e r a l , D y a d i c R e l a t i o n s h i p , and Sel f R a t i n g P r o f i l e s , see F igures 4.4, 4.5, 4.6, and 4.7. Interpretation O n scales r a t i n g Soc ia l D e s i r a b i l i t y and Defcns iveness , the case subject a t ta ined s tandard scores of 55 and 62 respect ive ly . T h e Defens iveness score, being greater than one s tandard d e v i a t i o n above the mean , s i g n i f i e d the p o s s i b i l i t y of some degree of defensiveness or ' f a k i n g good' in the o v e r a l l p r o f i l e . T h i s score was kept in m i n d in the in te rpre ta t ion of the p r o f i l e . By c o m p a r i n g the scores of the case subject w i t h those of the mother and brother , an assessment of the r isk of the p r o f i l e be ing i n v a l i d was made. In the o p i n i o n of the case invest igator , the p r o f i l e of the case subject was a v a l i d one, based on a compar i son of her scores w i t h those of the other f a m i l y members. -63- F i g u r e 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 for the f a m i l y ( ca lcu la ted by f i n d i n g the mean score fo r the seven c l i n i c a l subscales) was a s tandard score of 48, we l l w i t h i n the n o r m a l range. Wi th the except ion of the a f o r e m e n t i o n e d Defens iveness scale, the on ly score to f a l l out of the n o r m a l range (i.e. greater than one s tandard 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 Invo lvement . T h e subject's score of 38 suggested h igh levels of e m p a t h i c i n v o l v e m e n t between f a m i l y members , m u t u a l concern and a n u r t u r i n g and suppor t i ve i n v o l v e m e n t w i t h each other. Both the mother 's score (47) and brother 's score (54) suggested somewhat less pos i t i ve v iews o f this d i m e n s i o n , however both scores f e l l w i t h i n the no rmal range fo r n o n p r o b l e m a t i c f a m i l i e s in the n o r m i n g group. T h e subscales measur ing C o n t r o l , and V a l u e s and N o r m s , showed the greatest d i s p a r i t y of scores. The case subject a t ta ined a s tandard score of 41 on the cont ro l subscale. T h i s w o u l d suggest that she v iews the manner in w h i c h cont ro l and power is w i e l d e d w i t h i n the group as be ing a f a m i l y s t rength . The FAM i n t e r p r e t a t i o n gu ide suggested that ext reme low scores ( d e f i n e d as less than 40) i n d i c a t e patterns of p r e d i c t a b i l i t y yet f l e x i b i l i t y in the meet ing of c h a n g i n g demands , and that cont ro l and attempts at cont ro l arc la rge ly cons t ruc t i ve , e d u c a t i o n a l and n u r t u r i n g . T h e subject 's score on this subscale was in s i g n i f i c a n t contrast to her mother 's score, w h i c h at 65, was greater than 2 s tandard d e v i a t i o n s away . A score of this m a g n i t u d e w o u l d suggest that the mother v iews the issue of c o n t r o l as being p r o b l e m a t i c w i t h i n the f a m i l y . T h e FAM Administration and Interpretation Guide suggested that scores above 60 may s i g n i f y any of the f o l l o w i n g : "patterns of 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 to master the rout ines of ongo ing f a m i l y l i f e ; the f a i l u r e to perce ive and adjust to c h a n g i n g l i f e demands ; a lack of spontanei ty or its opposi te , chaos, in issues o f power and 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 ; con t ro l attempts 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 to both of these extreme scores, the brother scored 55 on this subscale. A number of possible explanations were evident for this disparity in scores. 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 and her mother showed 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 brother at a score of 48 appears to have perce ived t h i s as an area of somewhat greater st rength. T h o u g h there is some d i s p a r i t y in scores here, it was not cons idered s i g n i f i c a n t since a l l of the scores f e l l w i t h i n the n o r m a l range and also f e l l w i t h i n one s tandard d e v i a t i o n of each other . T h e other three c l i n i c a l subscales (Task A c c o m p l i s h m e n t , R o l e P e r f o r m a n c e 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 and the scores of the three f a m i l y members f e l l w i t h i n one s tandard d e v i a t i o n of each other. T h e mean O v e r a l l R a t i n g s ( for a l l three test takers) f e l l w i t h i n the no rmal range. In spite of s i g n i f i c a n t d i f f e r e n c e s on s p e c i f i c subscales ( Invo lvement , C o n t r o l and V a l u e s and Norms) the O v e r a l l R a t i n g s f e l l r e l a t i v e l y close ( w i t h i n one s tandard d e v i a t i o n ) to each other. It shou ld be noted that the n o r m i n g popu la t ion for the FAM docs not i n c l u d e f a m i l i e s w i t h adu l t c h i l d r e n no longer l i v i n g in the same d o m i c i l e as the parents. T h e case invest igator was assured by the Research C o o r d i n a t o r of the " F A M Research Project" that this ins t rument has been f o u n d to be v a l i d for f a m i l i e s at this stage, however , the re la t ionsh ip of this f a m i l y ' s scores to the scores of p r o b l e m a t i c and n o n p r o b l e m a t i c f a m i l i e s used as the re ference popu la t ion shou ld be in te rpre ted w i t h some c a u t i o n . -67- Figure 4.5 FAM PROFILE •So if o f / / So Hi cf «9 5> 70 En crj O ^•1 CO g> 70 H30 Subject Mother - 68 - Interpretation In r a t i n g her re la t ionsh ip w i t h her mother , the case subject scored an O v e r a l l R a t i n g of 51.5. T h i s was the average of the seven c l i n i c a l subscales (al l of w h i c h f e l l w i t h i n .5 s tandard dev ia t ions of the mean). T h e most ext reme score in a pos i t i ve d i r e c t i o n was on the subscale of Task A c c o m p l i s h m e n t (46). T h e most ext reme scores in a negat ive d i r e c t i o n were fo r the subscales of C o m m u n i c a t i o n (55) and of V a l u e s and N o r m s (55). Inspect ion of the g r a p h i c representat ion of the p r o f i l e ( f i gu re 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 in contrast , however , to the mother's ra t ing of this same re la t ionsh ip . A t an O v e r a l l R a t i n g of 40, the case subject's mother appeared to perce ive the r e l a t i o n s h i p as genera l l y be ing c h a r a c t e r i z e d by extreme adapt iveness . Inspect ion of the subscales in the mother 's p r o f i l e revealed a number of scores s i g n i f i c a n t l y d i ve rgent f r o m the those of the case subject. On a l l subscales except Task 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 in the d i r e c t i o n of 'greater s t rength ' than d i d the case subject. T h i s was most ev ident on the subscales of : A f f e c t i v e Express ion (28), Invo lvement (32), and C o n t r o l (40). S ince the focus of this s tudy d i d not i n c l u d e an intens ive c l i n i c a l assessment of the mother 's percept ion of 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 cou ld not be c o n c l u s i v e l y e x p l a i n e d . Based on the results of this q u e s t i o n n a i r e and on one i n t e r v i e w w i t h the mother , it was the case invest igator impress ion that the mother perceives her re la t ionsh ip w i t h her daughter as be ing charac te r i zed by openness, empathy and c a r i n g . -69- Figure 4.6 FAM PROFILE Subject Brother - 7 0 - In te rp re ta t ion T h e case subject's ra t ing of her re la t ionsh ip w i t h her brother showed a somewhat greater range in scores than 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 , fo r the case subject , was shown 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 Express ion and V a l u e s and Norms) . T h e A f f e c t i v e Express ion score suggested that c o m m u n i c a t i o n between the two, in the case subject 's o p i n i o n , has an 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 re la t i ve to the s i t u a t i o n (either ex t remely l a c k i n g or laden w i t h e m o t i o n a l i t y ) . He r score for the V a l u e s and N o r m s subscale s i g n i f i e d that she sees her values and those of her brother as be ing somewhat opposed. Wi th the except ion of these two subscale scores, there was very close agreement between the s ib l ings on their re la t ionsh ip (al l other subscale scores were w i t h i n two points of each other) . O n the subscales of A f f e c t i v e Invo lvement and V a l u e s and N o r m s the brother scored 53 and 54 respect ive ly . These latter two subscales represented the greatest d i s p a r i t y in scores w i t h the case subject , yet s t i l l f e l l w i t h i n one s tandard d e v i a t i o n . The brother 's O v e r a l l R a t i n g was 52.25, a p p r o x i m a t e l y one point less than the case subject's ra t ing . -71- F i g u r e 4.7 FAM PROFILE S u b j e c t ' s R a t i n g : Dyadic R e l a t i o n s h i p With F a t h e r - 72 - In te rp re ta t ion 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 (60) followed by a score of 58 on Affective Involvement. The Affective Expression score was identical to the score on the dyadic profile with the brother and suggested problems in the area of affective communication. The Affective Involvement score was within the high normal range. It suggested possible difficulty in the area of affective/emotional involvement (either too close or too detached). -73- F i g u r e 4.8 FAM PROFILE S e l f R a t i n g - 74 - Interpretation O n the Self R a t i n g scale, the case subject a t t a i n e d an O v e r a l l R a t i n g of 51.7: S ix of the seven scales f e l l between 47 and 54. The one ou ts tand ing score was f o r the subscale, V a l u e s and Norms . T h e score of 60 on this subscale, suggested some d is tu rbance centered on perce ived d issonance between the case subject's values and those of the f a m i l y genera l l y . T h i s score may also have been s h o w i n g c o n f l i c t in the area of f a m i l y rules, s p e c i f i c a l l y between overt and covert rules. These scores w i l l be discussed f u r t h e r in the context o f the o v e r a l l data c o l l e c t i o n i n Chapte r V . Social Support Questionnaire The results fo r the Social Support Questionnaire (SSQ) i n d i c a t e d that the case subject 's perce ived level of soc ia l support , across the s i tuat ions presented, ranged in number ( N score) f r o m 4 to 8 people (mean = 5.7). T h e authors repor ted , that in the i r research w i t h col lege students the N scores ranged 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. The case subject's S score ( sa t i s fac t ion level w i t h the support a v a i l a b l e ) was 6 (very s a t i s f i e d , the highest possible score) fo r a l l of the s i tuat ions rated. T h e range of S scores that the authors report was 5.12 to 5.57 w i t h an o v e r a l l mean of 5.38. T h e case subject 's results on this i ns t rument , suggested that she has a greater level of soc ia l support and is more sa t i s f ied w i t h the q u a l i t y of support a v a i l a b l e , than the re ference group supp l ied by the ins t rument 's authors . H o w e v e r , this c o m p a r i s o n may not have been a v a l i d one, s ince the reference group used is a sample of col lege students. There may be s i g n i f i c a n t d i f f e r e n c e s in the area of soc ia l support between this reference sample and other popu la t ions w h i c h have more in common w i t h the case subject. - 75 - Inspect ion of the i n d i v i d u a l test items revealed that the case subject had l is ted 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 of the s i tuat ions posed. The re la t ionsh ips l is ted appeared to represent both f a m i l y and f r i e n d s . T h o u g h the c o m b i n a t i o n s of people changed across s i tuat ions , the answers demonst rated that there were a number of people who recur red across a va r ie t y of s i tuat ions . These people i n c l u d e d : f a m i l y of o r i g i n members (i.e. mother , f a t h e r and brother) f r i e n d s and c o m m o n - l a w husband . T h e overa l l p ic tu re appears to be one of a c i r c le of close f r i e n d s and f a m i l y , who the case subject bel ieves can be re l ied upon to be suppor t i ve across a var ie ty of l i f e s i tuat ions . The consistent scor ing of sa t i s fac t ion level at ' 6 ' , ra ised the quest ion of whether or not this was a v a l i d r e f l e c t i o n of the ac tua l level of s a t i s f a c t i o n or i f this was some f o r m of 'response set.' T h i s quest ion cou ld not be d e f i n i t i v e l y a n s w e r e d , however , the i n t e r v i e w data suggested that there was a long h is tory of close and suppor t i ve f r i e n d s h i p s . T h e C r i t i c a l Inc idents In his d e s c r i p t i o n of the C r i t i c a l Inc ident T e c h n i q u e , F l a n a g a n (1954) d e f i n e d an ' i n c i d e n t ' as " . . . any observable h u m a n a c t i v i t y that is s u f f i c i e n t l y complete in i tse l f to permi t in ferences and p red ic t ions about the person p e r f o r m i n g the act" (p. 327). The i n c i d e n t was seen as " c r i t i c a l " i f it " . . . occurs in a s i tuat ion where the purpose or intent of the act seems f a i r l y c lear to the observer and where its consequences are s u f f i c i e n t l y d e f i n e d to leave l i t t le doubt c o n c e r n i n g its e f fec ts " (p. 327). In this s tudy , the d e f i n i t i o n s were m o d i f i e d s l i gh t l y . A ' c r i t i c a l i n c i d e n t ' was d e f i n e d as an event w h i c h occur red w i t h i n the awareness of the case subject and resulted i n an observable consequence to, or b e h a v i o r by the case subject , w h i c h lasted over some per iod of t ime. T h o u g h it was a c k n o w l e d g e d that a result or consequence may be of an a f f e c t i v e or c o g n i t i v e nature and hence not - 76 - be observab le , fo r the purposes of this s tudy , the event was r e q u i r e d to have some observable component ( though other nonobservable components , i f a c k n o w l e d g e d , were reported as wel l ) . T h e c l a s s i f i c a t i o n of the c r i t i c a l i n c i d e n t s is shown in T a b l e 4.1. TABLE 4.1 ECO-SYSTEMIC CLASSIFICATION OF CRITICAL INCIDENTS Incident I n d i v i d u a l # 1 - S u i c i d e attempt age 15 # 2 - F i r s t crossdressing in p u b l i c #3 -Change of surname # 4 - S u i c i d e attempt age 31 F a m i l y # 5 - M o t h e r d iscovers that subject has not at tended A i r Cadets #6 -d iscovery of letters re. S R S # 7 - t e l l i n g fa ther and brother about 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 C o m m u n i t y ( E d u c a t i o n a l ) # 9 - R i d i c u l e d by G r a d e 9 teacher # 1 0 - A t t e n d i n g T r a d e School ( M e d i c a l ) #1 1 -Psych iat r i s t makes t ranssexual d iagnos is # 12 -F i rs t response f r o m John H o p k i n s # 1 3 - P l a s t i c surgeon supports S R S #14 -be ing ca lmed by surgeon Perceived Result - Teacher becomes less abus ive - N e v e r dresses as a male aga in -Less concern w i t h h i d i n g the past, greater honesty - C h a n g e in re la t ionsh ips - 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 d iscuss ions about S R S -open c o m m u n i c a t i o n w i t h fa ther and brother - fee l ings of acceptance -less interest in school -becomes q u a l i f i e d ha i r s ty l is t -Subject wr i tes J . H o p k i n s C l i n i c -Subject cont inues to wr i te - r e f e r r a l to C l a r k e Inst i tute - r e l i e f and c o n f i d e n c e post surgery - 77 - T A B L E 4.1 (continued) 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 O F C R I T I C A L I N C I D E N T S ( V o c a t i o n a l ) #15-Subject begins to charge fo r h a i r s t y l i n g #16-buys f i r s t salon i n O x b o w #17-organizes c o m m u n i t y ha i r and f a s h i o n show. #18 -w ins p r o v i n c i a l ha i r c o m p e t i t i o n # 1 9 - f i r e d f r o m job in To ronto #20-Ex -boss asks Subject to re turn 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 d o w n (soc ia l/ f r iends ) # 2 3 - G o i n g to A i r Cadets # 2 4 - f a m i l y f r i e n d speaks to son and 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 ve w i t h b o y f r i e n d #26- jo ins West E n d P layers # 2 7 - m o v i n g i n w i t h c o m m o n - l a w ( c o m m u n i t y at large) #28-sees C h r i s t i n e Jorgcnson on T .V . #29-man on plane comments on at t ract iveness #30-go ing to bar w i t h cous in in T o r o n t o -ex t ra money a l lows fo r expans ion of the business - i s successfu l f i n a n c i a l l y - rece ives pos i t i ve p u b l i c a t tent ion -moves to R e g i n a -boss o f f e r s a job i n R e g i n a - re turns to R e g i n a - t r a p p e d by debts, unab le to sell -moves to V a n c o u v e r - fee ls h u m i l i a t e d does not return - the boys cease r i d i c u l i n g subject - re turns to R e g i n a -change in soc ia l l i f e -change in l i f e c i r cumstances -seeks i n f o r m a t i o n about t ranssexua l i sm -stops c r y i n g - inc reased c o n f i d e n c e and c o n t i n u e d s o c i a l i z i n g Situational Influences A s a result o f the i n t e r v i e w process, it was d iscovered that there were a range of i n f l u e n c e s and s i tuat ions w h i c h c o u l d not be c l e a r l y c l a s s i f i e d as inc idents (due to the i r lack of obv ious , b e g i n n i n g and end points) yet appeared to be s i g n i f i c a n t to the psycho log ica l and socia l ad justment of the case subject. They are presented in T a b l e 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 fo r the C r i t i c a l Inc idents . - 78 - 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 O F S I T U A T I O N A L I N F L U E N C E S Influence Perceived Result I n d i v i d u a l # 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 and cut ha i r # 3 - r e a l i z i n g that it made her fee l better to be honest w i t h people she cared about #4 -a lways fe l t re laxed as a w o m a n #5-one year spent cross- dress ing in T o r o n t o #6 -ongo ing depression 1980- 1984 F a m i l y #7-no re ject ing responses f r o m f a m i l y members (re. SRS) C o m m u n i t y #8 -be ing in t roduced to the G a y c o m m u n i t y in R e g i n a #9 -ongo ing in te rv iews w i t h psych ia t r i s t at the C l a r k e Inst i tute # 1 0 - b e f r i e n d i n g a w o m a n subject saw as self des t ruc t i ve #11 -occas iona l l y fee l ' r e a d ' due to vo ice -spent a lot of t ime a lone , sew ing - d u r i n g teens these p r o v i d e the subject w i t h a serv ice to o f f e r peers and as an adu l t these become v i a b l e v o c a t i o n a l s k i l l s - Immedia te f a m i l y a l l k n e w about subject's desire fo r S R S by 1971 (pr ior to c r o s s - l i v i n g in To ronto ) - d i d n ' t fee l that she had to w o r k at 'pass ing ' - c o n f i d e n t when 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 and excessive use of a l coho l and drugs - a l w a y s fe l t supported and taken ser ious ly - d e v e l o p i n g e m p a t h i c f r i e n d s h i p s -pos i t i ve therapeut ic a l l i a n c e w h i c h increased d e t e r m i n a t i o n and f a i t h in a b i l i t y to succeed - m o t i v a t i o n to change behav io r patterns of 1980-1984 -has at tempted to m o d i f y but unsuccess fu l l y - 79 - TABLE 4.3 A COMPARISON OF T H E CASE SUBJECT'S AND CASE INVESTIGATOR'S SIGNIFICANCE RATINGS OF THE CRITICAL INCIDENTS Number of Incidents 10 28* 29** 29* 28** 9 20* 18** 18* 20** 8 12* 17** 17* 10** 7 10* 13** 13* 09** 6 06* 01** 30* 30** 5 23* 23** 26* 26** 4 23* 14** 22* 22** 24* 24** 14* 06** 3 01* 12** 21* 21** 11* j j ** 27* 27** 2 15* 15** 19* 19** 04* 04** 08* 08** 1 09* 23** 05* 05** 16* 16** 03* 03** 07* 07** 1 2 3 4 5 6 Levels of Importance Column * Case Subject's ratings Column ** 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. This result will be discussed further in Chapter V. - 80 - CHAPTER V SUMMARY AND DISCUSSION T h i s project was based on the premise that the post operat i ve ad justment of t ranssexual i n d i v i d u a l s can be pos i t i ve 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, and post s u r g i c a l sex - reass ignment . T h e p r i m a r y purpose of this s tudy was to e x a m i n e the deve lopment and ongo ing adjustment of a s ingle i n d i v i d u a l . By f o c u s i n g on the cur rent p s y c h o l o g i c a l and soc ia l adjustment of this i n d i v i d u a l , and then a t tempt ing to d iscover what factors had been s i g n i f i c a n t to this person's ad jus tment , the researcher was able to emphasize the s i g n i f i c a n c e of the context 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 and to show the impor tance of the va r ious groups or systems w h i c h she has come in to contact w i t h over the years. T h i s has enr i ched the knowledge base in the area of t ranssexual ism and has a l l o w e d fo r a s h i f t in research focus ( w h i c h , h i s t o r i c a l l y , has largely ignored the e f f e c t of the people and 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 eco log ica l model fo r assessment gu ided the c l a s s i f i c a t i o n of the c r i t i c a l i nc idents revealed d u r i n g the i n t e r v i e w process. T h e m o d e l , w h i c h emphas ized 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 w i t h a va r ie t y of groups w i t h i n the e n v i r o n m e n t , served to h i g h l i g h t the e f f e c t of in te rpersona l va r iab les . T h e use of the three s t a n d a r d i z e d ins t ruments a l l o w e d fo r an assessment of the i n d i v i d u a l ' s current psychosoc ia l f u n c t i o n i n g . The h i s to r i ca l MMPI p r o f i l e s a l l o w e d a po r t raya l of change in 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 t ime span of the tests. T h e c o m p a r i s o n of the three MMPI p ro f i l es (admin is te red over a s ixteen year t ime per iod) o f f e r e d an oppor tun i t y to unders tand how this i n d i v i d u a l has deve loped and changed on the d imensions w h i c h this ins t rument measures. The results of this s tudy suggest a number of issues w h i c h appear 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 operat i ve adjustment of this person. - 81 - The Test Results A s reported in Chapte r IV , the results of the SSQ showed the number of support persons (N score) l is ted across the s i tuat ions presented, ranged f r o m 4 to 8 people, w i t h a mean score of 5.7. The authors reported a mean N score of 4.25 in the i r research w i t h a sample of 602 col lege students. W i t h re ference to this compar i son group , a l l that can be said is that the case subject 's mean N score is greater than the mean of the author 's sample. L o o k i n g more c lose ly at the subject's responses to s p e c i f i c quest ions, one sees a c e r t a i n repet i t ion of people l i s ted . T h i s suggests that , in the case subject's o p i n i o n , there is a g roup 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, and also w h o m she feels may be re l ied upon across a va r ie t y of s i tuat ions . T h i s i n f o r m a t i o n is consistent w i t h i n f o r m a t i o n 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 and f a m i l y of the case subject . One of the persons in te rv iewed descr ibed the exper ience of f i r s t meet ing the case subject and being "checked out" by the c i r c l e o f f r i e n d s of that t ime. It was reported that there was a sense of h a v i n g to prove onesel f , not to the subject , but to her f r i e n d s . Other persons i n t e r v i e w e d also noted the role of f r i e n d s h i p s and how the subject had a lways had a c i r c le of close, and at t imes protect i ve , f r i e n d s a r o u n d her. The M M P I p ro f i l es , f r o m the ear l iest a d m i n i s t r a t i o n o n w a r d , support the f i n d i n g that the subject d i d not v i e w hersel f as be ing s o c i a l l y i so la ted , in spite of whatever other d i f f i c u l t i e s she may have had. D u r i n g the process of the in te rv iews , the subject 's own descr ip t ions f r e q u e n t l y re tu rned to the theme of re la t ionsh ips . In her d e s c r i p t i o n of 1971, the year spent c r o s s - l i v i n g i n To ronto , the i so la t ion and lack of close f r i e n d s h i p s appeared to p lay a c r u c i a l role in what she descr ibed as poss ib ly the most d i f f i c u l t year of her l i f e . T h e impor tance of work and of be ing near people w h i l e at work , was discussed and appears to have been a mechan ism fo r c o p i n g d u r i n g this per iod . - 82 - In c o n j u n c t i o n w i t h th is , re lat ives in the Toronto area were repor ted to have p r o v i d e d some e m o t i o n a l support and contact d u r i n g this per iod of t ime. These d i f f e r e n t sources of data co l lec t ion are a l l consistent w i t h the results of the SSQ, s h o w i n g an i n d i v i d u a l who enjoys a close and s u p p o r t i v e ne twork of re la t ionsh ips . T h i s appears to be true not on ly in the present contex t , but also, to have been consistent th rough the majo r i t y of her adu l t h is tory . T h e Family Assessment Measure p r o v i d e d data on a va r ie t y of d imens ions of f a m i l y f u n c t i o n i n g , not on ly f r o m the case subject's po int of v i e w but f r o m those of the mother and the brother as we l l . In r a t i n g the f a m i l y as a whole , the case subject scores the d imens ions of C o n t r o l and A f f e c t i v e Invo lvement as areas of greatest s t rength . T h e score fo r A f f e c t i v e Invo l vement 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 of empathy and emot iona l invo lvement . T h e subscale C o n t r o l is also in terpreted as a d i m e n s i o n of adapt iveness fo r the subject. It is in te res t ing to note that the scores fo r A f f e c t i v e Express ion and C o m m u n i c a t i o n are i d e n t i c a l (50) and though h a r d l y 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 level of s t rength , w h i c h the A f f e c t i v e Invo lvement and C o n t r o l subscales are. A close inspect ion of these subscales suggests that , in the case subject's o p i n i o n , this f a m i l y is more e f f e c t i v e in ac t ion based d imens ions than in v e r b a l l y based ones. T h e d y a d i c p r o f i l e s reveal cer ta in consistencies across the three re la t ionsh ips (when rated by the case subject). In a l l three re la t ionsh ips (mother , brother and fa ther ) the C o m m u n i c a t i o n subscale is rated at a p p r o x i m a t e l y .5 s tandard d e v i a t i o n above the mean. The d i r e c t i o n of these three scores suggests that the subject feels that c o m m u n i c a t i o n between hersel f and i n d i v i d u a l f a m i l y members may not be as e f f e c t i v e as it cou ld be. V a l u e s and N o r m s is not rated by the case subject as p r o b l e m a t i c when 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 in terest ing that when she is respond ing to - 83 - quest ions r e g a r d i n g the component d y a d i c re la t ionsh ips , she rates this d i m e n s i o n f r o m scores of 55 ( re la t ionsh ip w i t h her mother) to 60 ( re la t ionsh ips w i t h father and w i t h brother) . 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 60. These consistent e levat ions in d y a d i c scores, coup led 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 iews components of her va lue system to be in c o n f l i c t w i t h those of her f a m i l y . In apparent oppos i t ion to th is , when 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 . A possible e x p l a n a t i o n is that she rates the f a m i l y as be ing r e l a t i v e l y congruent on this d i m e n s i o n , yet sees hersel f as somehow d i f f e r e n t f r o m them. T h i s incongruence does not then become ev ident u n t i l the d y a d i c re la t ionsh ips are e x a m i n e d . T h i s hypothes is is h i g h l y specu lat i ve and must be v i e w e d w i t h c a u t i o n ; however , it may poss ib ly re late to an u n d e r l y i n g theme of ' i so la t ion versus be long ing ' to be discussed later in this chapter . The Se 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 of the 7 subscales w i t h i n 4 points of the mean. O v e r a l l , it w o u l d appear that she v iews her a b i l i t y to f u n c t i o n w i t h i n the f a m i l y s t ructure (as it c u r r e n t l y exists) as be ing re la t i ve l y p rob lem f ree , w i t h the except ion of the a f o r e m e n t i o n e d subscale of Va lues and N o r m s . The cur rent Minnesota Multiphasic Personality Inventory shows no s i g n i f i c a n t e levat ions on c l i n i c a l scales. T h i s is a d r a m a t i c change when 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 showed elevat ions of greater than one s tandard d e v i a t i o n on Scales 2 & 3 and greater than two s tandard d e v i a t i o n s on Scales 7, 8 & 9. It is in te res t ing to note that the 1971 p r o f i l e supports the i n t e r v i e w d a t a , w h i c h stated that the h igh level of soc ia l support be ing measured c u r r e n t l y by the SSQ was r e l a t i v e l y consistent h i s t o r i c a l l y . In spite of an e levated Scale 8 (suggesting s c h i z o i d a l tendencies) the soc ia l in t rovers ion scale shows a score s l i gh t l y above the mean. T h i s suggests that though the subject may have been spend ing t ime alone - 8 4 - r u m i n a t i n g , and may have fe l t unaccepted by the w o r l d (and p r o b a b l y unaccepted by hersel f as wel l ) she d i d not perceive hersel f as being s o c i a l l y i so lated . T h e 1987 p r o f i l e shows a lower score ( raw score = 16) on the social i n t r o v e r s i o n scale; however the s c h i z o i d a l tendencies are no longer in ev idence. 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 ) , be ing e levated s l i g h t l y beyond one s tandard 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 quest ions of this subscale in a s te reotyp ica l f e m i n i n e f a s h i o n . T h i s does not necessar i l y c a l l the subject's in tegra t ion into the f e m i n i n e role into quest ion ; it does show that the role in tegra t ion is not based on t r a d i t i o n a l stereotypes. C o n s i d e r i n g the content of this scale, a score in the ' f e m i n i n e ' d i r e c t i o n w o u l d be of quest ionab le a d a p t a b i l i t y at this t ime in our society . T h i s too is a d r a m a t i c change f r o m the 1971 p r o f i l e w h i c h showed the subject scor ing at the 97th percent i le of this scale. In s u m m a r y , the s t a n d a r d i z e d tests have por t rayed the case subject as a person who is: (1) s o c i a l l y in tegrated ; (2) feels a f f e c t i o n and e m p a t h y w i t h her f a m i l y of o r i g i n , though she may have d i f f i c u l t y express ing i t ; (3) feels somewhat apart f r o m her f a m i l y on issues of ce r ta in basic va lues ; (4) demonstrates no ev idence of menta l i l lness ; (5) appears to der i ve pleasure f r o m l i f e ; (6) is nei ther excess ive ly sex - ro le stereotyped nor excess ive ly counter - s te reotyped . T h e C r i t i c a l Inc idents In r e v i e w i n g the c r i t i c a l inc idents , what is most s t r i k i n g is that of the 30 inc idents repor ted , 22 of them f a l l under the c l a s s i f i c a t i o n , " C o m m u n i t y . " T h i s c o n f i r m s an u n d e r l y i n g assumpt ion of this research project : that the i n d i v i d u a l exists and interacts w i t h a var ie ty of i n d i v i d u a l s and groups, a l l of w h i c h , to v a r y i n g degrees, exert an i n f l u e n c e upon the i n d i v i d u a l . The inc idents can be interpreted on several levels. When c l a s s i f i e d on the basis of the sub-systems i n v o l v e d , the reader is able to see the impact of separate - 85 - groups, a l l of 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 t imes in her l i f e . T h i s emphasis is an impor tant one because it h igh l i gh ts the s i g n i f i c a n c e of the context w i t h i n w h i c h the i n d i v i d u a l exists. T h e subject 's t ranssexua l i sm created a s p e c i f i c set of needs or wishes. A n example of this was the wish for sex- reassignment . A s a result of this w ish/need , ce r ta in sub-systems became ext remely i m p o r t a n t . Representat i ves of the m e d i c a l c o m m u n i t y , w i t h the i r power to support or not support the i n d i v i d u a l ' s goal of sex - reass ignment , came to have cons iderab le s i g n i f i c a n c e . Inspect ion of the inc idents i n this category reveal that the case subject was la rge ly supported by the phys ic ians w h o m she came into contact w i t h p r i o r to surgery . What seems impor tant is that none o f the m e d i c a l profess ionals appear to have quest ioned the seriousness of her request. T h o u g h the process was a long and 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 of 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 t imes have been reported in the l i te ra ture , (e.g., Bogden , 1974; M a s o n , 1980) T h e e f f e c t of the case subject's p re -operat i ve charac te r i s t i cs (i.e. f e m i n i n e character i s t i cs ) on other people, and as a result , thei r r e c i p r o c a l e f f e c t on her, arc c l e a r l y shown in the i n c i d e n t w i t h the grade 9 teacher ( inc ident #9, table 4.1). T h o u g h school had a l w a y s engendered c e r t a i n d i f f i c u l t i e s , such as p e r i o d i c teasing f r o m classmates, u n t i l grade 9 it had been a bearable , i f not pleasant exper ience ( a c c o r d i n g to ret rospect ive descr ipt ions) . N o a c a d e m i c problems were ev ident p r io r to this t ime. B e g i n n i n g in this year , and c o n t i n u i n g in 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 in school escalated, as d i d her desire to leave and attend t rade schoo l . R i d i c u l e f r o m the grade 9 teacher, and then aga in in grade 10 (the same teacher taught both years) appears to have been p i v o t a l , in terms of at t i tudes t o w a r d school . R i d i c u l e f r o m classmates also peaked d u r i n g this per iod . T h i s appears to have subsided however , a f ter i nc ident #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 number of ne ighborhood c h i l d r e n about the case subject - 86 - 'be ing d i f f e r e n t . ' It was not u n t i l a su i c ide attempt at age f i f t e e n , and the resu l t ing v is i ts to the school psychologist , that the teacher's behav io r was m o d i f i e d . By this t ime the subject w o u l d not be swayed f r o m her dec i s ion to stop her secondary e d u c a t i o n and commence a t tend ing t rade school i n To ronto . It was also toward the end of this per iod (1963) that the then f i f t e e n year - o ld case subject saw C h r i s t i n e Jorgenson (a post opera t i ve m a l e - t o - f e m a l c t ranssexual ) on te lev i s ion , and began to seek i n f o r m a t i o n about the procedure of sex - reass ignment . These two 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 , and r e m a i n e d constant u n t i l the successfu l comple t ion of each. A t t e n d i n g t rade school to study h a i r s t y l i n g f o r m a l i z e d and gave sanct ion to an a c t i v i t y the case subject had done (and been pa id for ) s ince her ear ly teens. Inc idents #15 through #22 are focused in the area o f vocat ion . Inc ident #15 occurs at about age f o u r t e e n , when the subject f i r s t began to be pa id for c u t t i n g ha i r . T h i s e f f e c t i v e l y was the beg inn ing of her career. By age twenty , the subject had bought her own salon in the town where she grew up. D u r i n g the in te rv iews this was descr ibed as a t ime of some soc ia l i s o l a t i o n , yet, a t ime of voca t iona l and f i n a n c i a l success. It was also d u r i n g this per iod that the subject o rgan ized an h i s t o r i c a l ha i r and f a s h i o n show w h i c h was rece ived f a v o r a b l y by the press and the p u b l i c . T h e young man who years before had been re fused a request to take sewing i n school had staged a successful f a s h i o n show (sewing the clothes h imse l f ) in the c o m m u n i t y w h i c h had prev ious ly censored h i m f o r his a t y p i c a l behav ior . T h e subject then entered a p r o v i n c i a l ha i r s t y l i n g c o m p e t i t i o n . He entered in three categor ies , w i n n i n g in two and p l a c i n g t h i r d in one. With this came recogn i t ion w i t h i n his trade and o f f e r s of work in more urban centers. T h i s resulted in a dec is ion to move to R e g i n a and the f o r g i n g of p ro fess iona l and personal connect ions w h i c h remain intact to this day . - 8 7 - D u r i n g the i n t e r v i e w s the case subject sa id that as a teenager her a b i l i t y to cut h a i r and to sew gave her a way to b u i l d re la t ionsh ips w i t h peers. One inc ident (#24), i n w h i c h the adu l t f a m i l y f r i e n d spoke to her o w n son and his f r i e n d s about the teasing of the case subject , supports this to an extent . It was a f te r this i n c i d e n t , that the boys are reported to have ceased teasing. T h e subject e x p l a i n e d that once the teasing stopped, she became f r i e n d l y w i t h this group and began sewing f o r them and c u t t i n g their ha i r . E v e n i f this i n t e r p r e t a t i o n (that the f o u n d a t i o n of those re la t ionsh ips was at least p a r t i a l l y based in the serv ice w h i c h the subject p rov ided ) is incor rec t , it is impor tant that she s t i l l perceives that her o f f e r i n g of these s k i l l s served as a sp r ingboard fo r the deve lopment of these f r i e n d s h i p s . B e g i n n i n g at t rade school in To ronto , f r i e n d s h i p s o f a somewhat d i f f e r e n t nature are repor ted . D u r i n g this t ime, the re la t ionsh ips appear based on a m u t u a l interest in h a i r s t y l i n g as we l l as other ac t i v i t i es such as m u s i c , go ing to cafes , etc. rather than in the o f f e r i n g of sk i l l s or services. T h e case subject reported that it was in T o r o n t o where she f i r s t fe l t that she d i d not stand out and was free to act as she pleased. L a t e r , in R e g i n a , w h i l e s o c i a l i z i n g in the gay c o m m u n i t y , she reported this same sense of not s tand ing out , and of meet ing people who understood about "be ing d i f f e r e n t . " T h i s i n i t i a l i n v o l v e m e n t w i t h the gay c o m m u n i t y was p r c - o p e r a t i v e , and occur red p r io r to the subject 's commencement of c r o s s - l i v i n g . She stated that though the i n d i v i d u a l re la t ionsh ips were c m p a t h i c ones, she d i d not cons ider hersel f to be homosexual . T h i s is consistent w i t h reports expressed in the research that though the sexual o r i e n t a t i o n may be homosexual or heterosexua l , it is the gender o r i e n t a t i o n w h i c h is p r i m a r y in the i n d i v i d u a l ' s d e f i n i t i o n of self (e.g. Ste iner , 1985). D u r i n g the t ime of this research project , the subject and her b o y f r i e n d made the dec is ion to l i ve ' c o m m o n - l a w . ' For the subject , this i n v o l v e d not only a - 88 - c o m m i t m e n t to the re la t ionsh ip , but also to the respons ib i l i t ies of be ing a parent: the par tner brought to the re la t ionsh ip a three -year o ld son f r o m his prev ious mar r iage . T h o u g h he had custody of the c h i l d at the t ime of the dec is ion to co- hab i ta te , a custody d ispute w i t h the b i o l o g i c a l mother ensued. F o r the case subject , this i n v o l v e d her t ranssexua l i sm e f f e c t i v e l y be ing 'he ld up to p u b l i c s c r u t i n y , ' as her f i tness to be a parent (as we l l as that of the boy's fa ther ) was argued by representat ives of the f a m i l y court system. It was the dec is ion of the court to a w a r d temporary custody to the subject and boy's fa the r , and to r e v i e w the case aga in in one year. It is notewor thy that in the report to the court ( compi led by the soc ia l worker who had s tud ied both home env i ronments ) , it was stated that the subject was perce ived to be able to p rov ide s t a b i l i t y fo r the c h i l d , and demonst rated a c lear a b i l i t y to parent. H e r t ranssexua l i sm was seen by the soc ia l w o r k e r , and u l t imate l y by the court , not to be a b a r r i e r to f u l f i l l i n g the materna l role. The Situational Influences T a b l e 4.3 consists of 11 ongo ing i n f l u e n c e s or issues uncovered d u r i n g the i n t e r v i e w process. They have been c l a s s i f i e d us ing the same eco-systemic c l a s s i f i c a t i o n scheme used w i t h the c r i t i c a l inc idents . 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 the i r lack of obv ious b e g i n n i n g and end points . O f the 11 i n f l u e n c e s c i t e d , 6 (55%) of them are c l a s s i f i e d at the " I n d i v i d u a l " leve l . A l t h o u g h these in f luences appear d iverse and v a r i e d , it is notewor thy that this large a p r o p o r t i o n of them are at this level of c l a s s i f i c a t i o n , whereas on ly 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 level . These i n f l u e n c e s appear to relate to a s ty le , or way of be ing . In f luence #1 (the lack of a t h l e t i c s k i l l s and resu l t ing t ime spent alone) and i n f l u e n c e #2 ( learn ing to sew and later to cut ha i r ) resulted in - 89 - the deve lopment of s k i l l s w h i c h in tu rn appear to have later f a c i l i t a t e d teenage re la t ionsh ips (or so the case subject believes). The r e a l i z a t i o n that openness and honesty , w i t h s i g n i f i c a n t others, cou ld have pos i t ive results ( i n f l u e n c e #3), lead to d isc losures (p re -operat i ve ly ) of the desire for sex - reass ignment (and resu l t ing f r o m that d isc losure , f a m i l y support fo r the process, [ i n f luence #7]). F r o m the data a v a i l a b l e we cannot te l l i f i n f l u e n c e #6 is t r u l y an i n f l u e n c e or a result (i.e. d i d the depression result in v o c a t i o n a l i n s t a b i l i t y and a lcoho l and d r u g abuse, or v ice -versa?) . We also are not able to assess the degree of the depressive symptomology . T h e " C o m m u n i t y " level i n f luences are focused on var ious types of re la t ionsh ips . The f o r g i n g of f r i e n d s h i p s w i t h i n the context 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 fo r the deve lopment of c m p a t h i c f r i e n d s h i p s and fee l ings of be long ing , yet also of being apart . A l t h o u g h the subject reported that she thought that her f r i e n d s understood her fee l ings of 'be ing d i f f e r e n t , ' it was c lear to her that she was not homosexual and as a result w o u l d never feel comple te l y a part of this c o m m u n i t y . T ranssexua ls and homosexuals , a l though s h a r i n g the charac te r i s t i c of be ing sexual m i n o r i t i e s , are c l e a r l y not the same phenomenon . T h i s c o m m o n fac to r of m i n o r i t y status may serve to f a c i l i t a t e acceptance of each other , yet it w o u l d not (and d i d not , f o r the case subject) , result in the e r a d i c a t i o n of the i r d i f f e r e n c e s . In f luences #9 and #10 represent re la t ionsh ips w h i c h the case subject acknowledges as h a v i n g had a great enough impact to result in a change of behav io r . T h i s is consistent w i t h other data gathered w h i c h h i g h l i g h t the i m p o r t a n c e of h a v i n g m e a n i n g f u l re lat ionsh ips . In a less obv ious manner , i n f l u e n c e #11 cou ld also be related to this issue of re la t ionsh ips . T h e f e e l i n g of be ing ' r e a d ' due to the q u a l i t y of her vo ice , cou ld c o n c e i v a b l y cause ei ther the - 90 - subject or the person w h o m she fe l t ' r ead ' by to w i t h d r a w , thereby negat ive ly a f f e c t i n g the f o r m a t i o n of that (probably t rans i to ry ) r e l a t i o n s h i p . In s u m m a r y , the in f luences c i ted here appear to revo lve a r o u n d two p r i m a r y issues. Those 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 leve l relate s t rongly to the subject's i n d i v i d u a l style or way of be ing in the w o r l d . Those c l a s s i f i e d at the F a m i l y and C o m m u n i t y levels relate to the f o r m a t i o n and main tenance of d i f f e r e n t types of in te rpersona l re lat ionships . U n d e r l y i n g Themes A s stated at the outset, the eco-systemic c l a s s i f i c a t i o n scheme served to h i g h l i g h t the im p or tan ce of the context i n w h i c h the i n d i v i d u a l l ives . When l o o k i n g at the inc idents c o l l e c t i v e l y though , it appears that there are several more general 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. These themes centre on issues of : acceptance versus re jec t ion , i so lat ion versus be long ing , and competency versus incompetency . A c c e p t a n c e as a w o m a n , by society and its i n d i v i d u a l representat ives ; a f f i r m a t i o n of the i n d i v i d u a l ' s competency , whether that be v o c a t i o n a l l y , or in roles, such as that of 'mother ; ' and the need to belong, not a lways to be apart and d i f f e r e n t f r o m others, are themes w h i c h permeate the inc idents and i n f l u e n c e s c i ted . T h e cho ice to l i ve c o m m o n - l a w and to take on the role of parent , and then the ensu ing custody d i spute , may be seen as i n v o l v i n g a l l of these i n d i v i d u a l themes. In the s i x th i n t e r v i e w , w h i c h was focused on the area of ' romance , ' the inves t igator quest ioned the subject about the m e a n i n g of , and reasons f o r , t a k i n g on the roles of w i f e and mother . T h o u g h a number of issues r e l a t i n g to fee l ings of love and c a r i n g were d iscussed, the subject sa id also that it was the f u l f i l l m e n t of and o ld d r e a m : the d ream of becoming w i f e and mother . - 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 sub- systems 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. -92- What are the consequences of these fac tors , and w h y are they seen as s i g n i f i c a n t in the subject 's post operat ive adjustment? 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 fac tors i d e n t i f i e d as s i g n i f i c a n t , what is the i r order of 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. As one looks at these ratings, the level of disagreement appears somewhat less. 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 - 9 3 - levels was not c lear . It is d o u b t f u l , however , that this e x p l a n a t i o n can be used to e x p l a i n a l l d i f f e r e n c e s between rat ings. Wi th the data a v a i l a b l e , conc lus ive exp lanat ions of this result remain e lus ive . It is a poss ib i l i t y though , that much of the d isagreement resides w i t h i n d i f f e r e n t percept ions of what const i tutes the ' s i g n i f i c a n c e ' of an inc ident (i.e. the invest igator 's need fo r a tang ib le result and the subject 's sub ject ive unders tand ing of the i n t a n g i b l e results of inc idents ) . T h e Resul ts W i t h i n T h e C o n t e x t O f O t h e r Research It is in te res t ing and impor tant to look at this project w i t h i n the context of past studies. T h e intens ive case study method used here has generated a mass of d a t a , w h i c h is broader in scope than the research quest ions have r e q u i r e d . T h i s sect ion of the study therefore looks at the r e l a t i o n s h i p of this project w i t h past e m p i r i c a l w o r k by f o c u s i n g not on ly on the research quest ions , but on the data base as a whole . E v i d e n c e of increased levels of self esteem (post opera t i ve l y ) f o u n d in the MMPI p r o f i l e s is in keep ing w i t h the f i n d i n g s of B a l l (1981) and S k a p c c and M a c k e n z i e (1981). The o v e r a l l improvement in pre - and post operat i ve MMPI p r o f i l e s supports the work o f F l e m i n g et a l . , (1981) who showed s i g n i f i c a n t i m p r o v e m e n t s f o l l o w i n g sex - reassignment i n the p r o f i l e generated by this ins t rument . What this s tudy went on to suggest is that the i m p r o v e m e n t may c o n t i n u e over a long per iod of t ime , as ev idenced by the change f r o m 1975 and 1987 p r o f i l e s . S ince no studies were f o u n d in the l i te ra tu re that s tud ied the MMPI d imens ions (post opera t i ve l y ) over a comparab le length of t ime , it cannot be stated w i t h c e r t a i n t y whether this is a s i g n i f i c a n t t rend or a result p e c u l i a r to this i n d i v i d u a l . M e y e r and Reter (1979) d i d show that in a l l three of the groups they s tud ied (operated, unoperated and subsequent ly operated) , there was general t rend to p s y c h o l o g i c a l and soc ia l improvement , w h i c h is s i m i l a r to the present result. -94- The 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 and interpersonal variables which affect post operative adjustment. 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. - 9 5 - T h i s project f o l l o w s in the t r a d i t i o n of a smal l number of studies w h i c h have h i g h l i g h t e d and posed quest ions about the e f f e c t of the e n v i r o n m e n t on the i n d i v i d u a l . T h i s group of studies w o u l d i n c l u d e L e v i n e and S h u m a k e r (1983), M a s o n (1980), Oles (1977), and Y a r d l e y (1976). Oles (1977), i n her d iscuss ion of psychotheraput i c issues, states that the area of e m p l o y m e n t is an impor tant and o f ten d i f f i c u l t one fo r t ranssexual people. A s an e x a m p l e , she points to the d i l e m m a of whether or not the i n d i v i d u a l s should d isc lose the i r t ranssexua l i sm to employers . In her o p i n i o n , i f the person discloses, they r isk be ing f i r e d ( w h i c h happened to the case subject in Toronto ) . If they do not d isc lose , they may f i n d themselves l i v i n g in fear of be ing d iscovered (an exper ience also re lated by the case subject) . Y a r d l e y (1976) hypothesizes that acceptance by the therapist of the cross- gender desire of the pat ient , is a pos i t i ve prognost ic i n d i c a t o r . Y a r d l e y does not e laborate f u r t h e r on this hypothesis . In the data c o l l e c t i o n fo r this s tudy , the subject d i d report a be l ie f that the re la t ionsh ip between hersel f and her p s y c h i a t r i s t at the C l a r k e Inst i tute had a s i g n i f i c a n t pos i t i ve impact w h i l e she was in the stage of c r o s s - l i v i n g . The subject descr ibed this impact as a f e e l i n g of being "cha l lenged to succeed." Without more e labora t ion 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 this be l ie f (of the case subject) is in support of i t . Resu l t s of this study appear to be consistent w i t h the d e s c r i p t i o n of Mason (1980), who stated that the c l ient 's fee l ings of be ing accepted by the therapist and/or c l i n i c a l team leads to increased fee l ings of self esteem. In ret rospect ive d e s c r i p t i o n s , the case subject descr ibed how any response f r o m representat ives 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 iagnos is as t ranssexual (even i f the response i tse l f was not posi t ive) encouraged her to cont inue to seek S R S . F r o m the data a v a i l a b l e we cannot say pos i t i ve l y that these ret rospect ive descr ip t ions demonst rate increases in self esteem. It does appear however , that fee l ings of - 9 6 - be ing encouraged and a f f i r m e d are being descr ibed and that these may be related i n some w a y to increases in self esteem. T h e r e was no suggestion here that the case subject p laced s i m i l a r const ra ints and l i m i t s on the theraput i c re la t ionsh ip (due to the a b i l i t y of the psych ia t r i s t to recommend f o r or against SRS) as was descr ibed by L e v i n e and S h u m a k e r (1983). Limitations of the Study T h i s s tudy has descr ibed the exper ience of an i n d i v i d u a l . T h e data cannot be genera l i zed . It has p r o v i d e d a po r t raya l of the psycho log ica l and soc ia l ad justment of one t ranssexual . U n l i k e fo rms of research w h i c h attempt to generate i n f o r m a t i o n w h i c h can be genera l i zed to a p o p u l a t i o n , this mode of research prov ides i n - d e p t h knowledge of one person. T h i s methodology has succeeded in p r o v i d i n g deta i l s about one case, and generat ing quest ions to ask across a larger sample of t ranssexual people. T h e use of a number of sources of data c o l l e c t i o n (h i s to r i ca l records and test scores, i n t e r v i e w s w i t h f a m i l y and f r i e n d s , case subject i n te rv iews and cur rent test scores) increases c o n f i d e n c e in the v a l i d i t y and in the r e l i a b i l i t y of the results. C o n c l u s i o n s r e g a r d i n g the subject's h i s to r i ca l f u n c t i o n i n g wou ld have been st rengthened had more deta i led case record ings f r o m the C l a r k e Inst i tute been made a v a i l a b l e . U n f o r t u n a t e l y , this was not possible. T h i s s tudy is a f o u n d a t i o n upon w h i c h , by the process of a n s w e r i n g the quest ions it raises, and 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 body of knowledge i n the area of post operat ive t ranssexua l i sm may be const ructed . 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 . V i e w e d as a source of d a t a , of hypotheses, a n d of quest ions for f u t u r e research projects , the usefulness of the project becomes c lear . - 9 7 - Implications and Suggestions For Future Research T h e n u m b e r of . c r i t i c a l inc idents w h i c h were f o u n d at the " C o m m u n i t y " leve l of the c l a s s i f i c a t i o n scheme suggests that research needs to address the impact of negat ive and pos i t i ve responses f r o m these s p e c i f i c groups (e.g. m e d i c a l c o m m u n i t y , f r i e n d s , etc.) on psychosocia l f u n c t i o n i n g at the p re -opera t i ve , as we l l as post operat i ve stages. T h e hypotheses put f o r t h by Y a r d l e y (1976) regard ing the e f f e c t on outcome, of acceptance by the therapist of the t ranssexual 's desire for sex - reass ignment , remains untested. In this s tudy , what appears to have been a pos i t i ve therapeut i c a l l i a n c e between the case subject and her psych ia 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 in terms of self c o n f i d e n c e and d e t e r m i n a t i o n to overcome obstacles. The e f fec t of d i f f e r e n t therap is t/c l ient re la t ionsh ips on h a b i l i t a t i o n and outcome in the post operat i ve gender ro le , remains an impor tan t but u n c h a r t e d area of study w i t h this p o p u l a t i o n . O u t c o m e studies, in the i r attempts to measure the degree o f post operat i ve success or f a i l u r e , usua l l y i n c l u d e some r a t i n g of employment f u n c t i o n i n g . T h i s project has suggested that the mean ing of employment transcends — a n d is much more complex— than an a b i l i t y to be s e l f - s u p p o r t i n g . F o r the person s tud ied here, career success appears to have increased fee l ings of c o n f i d e n c e and self wor th (af ter a c h i l d h o o d m a r k e d by episodes of r i d i c u l e and pervas ive fee l ings of being ' d i f f e r e n t ' and 'odd') . T h e e f f e c t of e m p l o y a b i l i t y and career success/fa i lu re on such d i m e n s i o n s as self image (both pre- and post opera t i ve l y ) is another area of possible s tudy . T h i s also w o u l d suggest that research in the area of vocat iona l c o u n s e l l i n g , and into what the s p e c i f i c needs of this p o p u l a t i o n may be, wou ld seem a v a l u a b l e area of study. Improved soc ia l and f a m i l i a l i n tegra t ion and acceptance , 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 in the l i te ra ture . T h e struggle fo r an ongo ing sense of ' b e l o n g i n g ' appears to be a p r i m a r y theme w i t h this person. When one - 9 8 - considers the exper ience , re lated by many t ranssexuals , of f e e l i n g as i f they are born in to the w r o n g body , this theme has i n t u i t i v e v a l i d i t y . P r e - o p e r a t i v e l y , the t ranssexual person not on ly feels d i f f e r e n t and isolated f r o m others, but also feels incongruent w i t h , and in a fash ion isolated f r o m , his or her o w n body. Research w h i c h attempts to ascerta in i f this sense of i so la t ion is t r u l y c o m m o n in the t ranssexual p o p u l a t i o n (both at the in te rpersona l and i n t r a p s y c h i c levels) and i f so, then in what ways it may be decreased, seems an area of pa ramount i m p o r t a n c e to counsel lors 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. (1986) Psychosoc ia l Outcomes of Sex Reass ignment Surgery . Journal of Consulting and Clinical Psychology. 54(2), 183-189. A l l p o r t , G . W. (1962). 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Case study research design and methods. B e v e r l y H i l l s , C A . : Sage P u b l i c a t i o n s - 104 - APPENDIX A Letters of Introduction - 107 - APPENDIX B Consent Forms - 108 - SUBJECT'S CONSENT FORM 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 - P A R T I C I P A N T ' S C O N S E N T F O R M I agree to p a r t i c i p a t e in a research project on post opera t i ve t ranssexua l i sm. I unders tand that p a r t i c i p a t i o n in this study is v o l u n t a r y and that I a m free to w i t h d r a w at any t ime, or refuse to answer any quest ion . I unders tand that I w i l l be i n t e r v i e w e d and that th is process w i l l take a p p r o x i m a t e l y two hours of my t ime. 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 , and w i l l be destroyed at the end of its usefulness. - 110 - APPENDIX C A Detailed Interview Guide - I l l - 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. - 1 1 7 - 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 I n f o r m a t i o n ) I n t r o d u c t i o n : "I w o u l d l i k e to begin these in te rv iews by a s k i n g you some basic i n f o r m a t i o n about your l i f e f r o m b i r t h through to the present. T h i s w i l l g ive me a basic f r a m e w o r k to better understand the i n f o r m a t i o n we w i l l d iscuss in the c o m i n g in te rv iews . " Quest ions and Top ics to be covered: 1. F a m i l y C o n s t e l l a t i o n (Genogram) 2. P lace of b i r t h 3. Res idences l i v e d in to the present 4. E d u c a t i o n a l h is to ry (schools, trade school , etc.) 5. E m p l o y m e n t h is tory 6. M e d i c a l h is tory 7. T r a n s s e x u a l h is tory - f i r s t thoughts of f e e l i n g as a woman f i r s t h e a r i n g about t ranssexual ism and sex- reassignment - f i r s t exper ience cross dressing - p o i n t of l i v i n g as a woman T h e purpose of this i n i t i a l i n t e r v i e w was to establ ish a c h r o n o l o g i c a l f r a m e w o r k and to gather basic i n f o r m a t i o n . It a t tempted to a c c o m p l i s h a general l i f e o v e r v i e w rather than an intens ive study of events such as the f o l l o w i n g i n t e r v i e w s d i d . - 118 - I n t e r v i e w w i t h Subject 's mother and fa ther (to be i n t e r v i e w e d separate ly ) 1. Please t h i n k back to the t ime when T e r r y was a c h i l d , say before the age of ten. D i d she have many f r i e n d s ? Were they boys? G i r l s ? Both? 2. A r e there any issues or problems re la t ing to soc ia l l i f e w h i c h stand out f r o m this t ime? 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 , get t ing a l o n g w i t h her teachers). 4. A r e there any events f r o m these f i r s t few school years w h i c h stand out fo r you? 5. Once T e r r y reach her teenage years d i d you ever suspect that someth ing was not r ight or was t r o u b l i n g her? 6. Was it T e r r y who f i r s t to ld you about her suspected t ranssexua l i sm? When d i d this happen? H o w d i d she go about t e l l i n g you? What was your react ion? 7. A f t e r the i n i t i a l d isc losure , d i d you cont inue to discuss i t? What were those discussions l ike? What stands out ( i f a n y t h i n g ) f r o m those discussions? 8. What was the react ion of your spouse? Y o u r son? Other re lat ives? F r iends? 9. Was T e r r y aware of these reactions? 10. R e m e m b e r back to the f i r s t t ime you saw T e r r y dressed as a w o m a n . What was your react ion? What d i d you t h i n k ? H o w d i d you behave? - 1 1 9 - 11. What was your re la t ionsh ip l i k e d u r i n g this per iod? 12. What was the react ion of your spouse to this change Ln T e r r y ? What was the react ion of your son? Other re lat ives? F a m i l y f r i ends? 13. D i d people discuss the s i tua t ion openly? 14. Was T e r r y aware of the react ions 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 per iod? 15. What is your cur rent re la t ionsh ip w i t h T e r r y l i k e ? 16. D o you fee l that T e r r y is d o i n g we l l today? 17. D o you fee 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 of be ing a t ranssexual? C o u l d you give some examples? 18. D o you t h i n k that T e r r y is better o f f fo r the sex- reassignment process? Why? 19. Do you t h i n k of T e r r y as a woman? In te rv iew w i t h the Case Subject 's brother 1. T h i n k back to when T e r r y was a smal l c h i l d , say before the age of ten. D i d she have many f r i e n d s ? Boys? G i r l s ? 2. A r e there any p a r t i c u l a r soc ia l problems or successes w h i c h stand out fo r your f r o m this t ime? 3. Were you and she close d u r i n g this t ime? If so, what 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 in e lementary school . H o w d i d she get a long? (e.g. a c a d e m i c a l l y , w i t h teachers, etc.). H o w about in h igh 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 you t h i n k that T e r r y is do ing wel l? In what way(s)? 19. What/who has helped her most? 20. What/who has h i n d e r e d or hurt her? 21. D o you t h i n k that T e r r y is better o f f fo r the sex- reass ignment surgery? Why? 22. D o you t h i n k of T e r r y as a woman? In te rv iew #3 w i t h the Case Subject. The top ic is ' f a m i l y l i f e ' and the t ime focus , is f r o m the ear l iest reco l lect ions , to the present. 1. T h i n k back to the t ime before you entered school . Were those happy times? C a n you tel l me some of the events or memories w h i c h make you remember them the way you do? 2. What was your r e l a t i o n s h i p w i t h your mother l i k e d u r i n g that t ime? Wi th your fa ther? 3. What was your re la t ionsh ip w i t h your brother l i ke? Were you and he close? In what way? 4. D i d you do things as a f a m i l y ? C a n you give some examples? 5. What stands out fo r you f r o m this per iod? What seems i m p o r t a n t ? 6. Y o u ' v e to ld me that you were taken to see a doctor because you wou ldn ' t p lay w i t h "boy's toys". H o w o ld were you when this occur red? Do you remember i t? If so, what d i d you unders tand about i t , at the t ime? 7. D i d you fee l loved and approved of by your mother d u r i n g this per iod of t ime? By your father? - 122 - 8. A s you grew o lder , d i d these fee l ings ( re la t ing to love and approva l ) r e m a i n stable or d i d they change in some way? If so, can you e x p l a i n how they changed? 9. D i d you ever fee l pressure to c o n f o r m in any way? (For example : as a male , soc ia l l y , a c a d e m i c a l l y , i n choos ing a p ro fess ion , etc.). 10. What was h o m e l i f e l i k e when you were a teenager? 11. What events stand out fo r you f r o m this t ime? 12. When you d isc losed that you thought you were a t ranssexua l , what happened? What were the react ions of the people you disc losed to? Whom d i d you te l l f i r s t , second, etc.. 13. When d i d you leave home? What were your reasons f o r l e a v i n g home and your fee l ings s u r r o u n d i n g the move? 14. D i d you cont inue to see your parents? H o w was your r e l a t i o n s h i p d i f f e r e n t ? H o w was it the same? 15. D i d you fee l more or less accepted by your parents a f t e r you moved out , or d i d your fee l ings of acceptance r e m a i n the same? What were the type of things your parents d i d to make you feel this way? 16. H a v i n g d isc losed your t ranssexual ism to your parents d i d you ever fee l rejected as a result of it? D i d you ever regret t e l l i n g them? 17. D i d they try and learn about t ranssexua l i sm and about the process you were going through? - 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? Have you ever been dissatisfied? Interview #5 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? What kinds of activities did you do with them? - 125 - 2. D i d you o f ten fee l lone ly or isolated? C a n you remember s p e c i f i c t imes when you fe l t l i k e lonely and/or iso lated? Please te l l me about these. 3. Who was the f i r s t f r i e n d you to ld about your fee l ings of be ing the w r o n g gender? What was the i r react ion? D i d it encourage or d iscourage you f r o m t e l l i n g others? D i d it change your r e l a t i o n s h i p w i t h that person? 4. A s you began to l i ve as a w o m a n , d i d you have close f r i e n d s ? 5. T e l l me about these f r i e n d s . Were they accept ing? S u p p o r t i v e ? Re jec t ing? 6. D i d you have f r i e n d s who were also t ranssexual? C a n you te l l me about those re lat ionships? 7. D i d you have f r i e n d s who stayed constant th roughout the process of sex - reassignment? 8. A s you were go ing through that process, d i d you fee l that you c o u l d c o n f i d e in your f r iends? D i d you fee l understood by them? What made you fee l that way? 9. D o you fee l that you can c o n f i d e in your present f r i e n d s . Do you fee l that they are 'deep f r i e n d s h i p s ' ? C a n you te l l me about these re lat ionships? 10. Is what you want f r o m f r i e n d s h i p s now, d i f f e r e n t than before S R S ? In what ways? A r e you gett ing what you want f r o m your cur rent f r i endsh ips . Is there any area in w h i c h you are d i ssat i s f ied? - 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 pre- operatively) 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. It is presented here in an attempt 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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