What do transsexuals have for breakfast?

Christine Burns M.Sc.

M.Sc., Researcher, Gender Trust Associate.
Gendys Conference, 1994

 
Where do the generalisations you hear about transsexuals come from and to what extent do they stand up to scrutiny? Is the public (and even professional) stereotype of this part of society wide of the mark? . . . And, if so, what implications does that continue to have for the assessment, care and social integration of this group? This is a preliminary report on the results of a questionnaire-based survey distributed over the first nine months of 1994 to the members of the Gender Trust aimed at determining whether the generalisations and stereotypes are representative of the facts. It is based on the 58 responses that had been received up to mid-August 1994 and, although this is a smaller number than hoped, the numbers are comparable to those used in other contemporary studies and the results still therefore worthy of interpretation.

Much of what is quoted as fact about transsexuals cannot in practice be traced to hard evidence. Since also some of the anecdotal observation of professionals working in the field may have been influenced in the past by the clients' assumption of the need to fit into certain stereotypes in order to be taken seriously, a fresh look, soliciting honest answers and carried out by a body which is not perceived to fulfil a gatekeeper role was felt to be of great value in hopefully setting the record straight.

There were many questions that came to mind in designing the questionnaire . . .

Is there anything characteristically typical about transsexuals? How much do they earn? What sort of work do they do? How educated are they? What sort of relationships do they form ... particularly during and after treatment? Did they really discover their nature sitting under a piano at the age of four?

How do transsexuals stand in relation to their parents, brothers and sisters? Do they often have children of their own? Do they have a religion? How does that religion see their situation?

Are they happy? If not, why not?

How old were they when they first felt something was wrong, and how old when they later declared themselves transsexual? Is there some relation between the two?

How tall, how heavy? How often is their physique a problem? Are they set to be (or already) surgery junkies? In what ways do they feel they're stigmatised?

What are the commonest problems arising from their treatment . . . in their view?

And, of course, what sort of medication do they take and is this being scientifically and consistently prescribed and monitored in line with the advance of clinical knowledge in this field?

The questionnaire was distributed with the Christmas 1993 issue of GEMS News, to about 3-400 people in total. Arrangements were also made, over the ensuing months, to send the questionnaire to all the new members which the trust has acquired. As at 20th August 1994, 58 responses had actually been received, which is less than the hundred hoped for, but twice the size of some of the professional samples on which a number of learned papers are based. It's something between a 15% and 20% response (the vagueness resulting from the fact that it is unclear, with this method of distribution, how many questionnaires finally reached their target).

The questionnaire was designed in two sections, each filling two sides of an A4 sheet.

The first section was sent to everybody and covered questions that apply equally to pre- and post-operative people, M to F and F to M . . . plus the transvestites and don't know's.

The second section was designed specifically for the group that each person belongs to.

Section 2A was for POST op M to F people.

Section 2B for the PRE op M to F's (and in fact anybody born with a willy)

Section 2C was for the F to M's . . and no distinction was made about where they were up to since they're a much smaller group and there is no one definitive operation in the same way as for M to F's

Of the 58 questionnaires received, in various states of completion as at 20th August, 53 were from people with "Boy" written on their birth certificate and 5 labelled at birth as "Girl."

Of the former group, 49 classed themselves as MF transsexual, 3 as transgenderists and one as TV. Of the other five, four said they were FM transsexual and one, interestingly, labelled themselves as a TV.

With such a small sample of F to M people to analyse, it was decided to exclude these and the TV's from the rest of the analysis and to concentrate on the group of 49 M to F transsexuals.

Of those 49:

• 7 had undergone gender reassignment surgery
• 5 had been approved for this and were waiting
• 21 were waiting for a referral
• 14 hadn't made their mind up at that stage
• 1 wasn't intending to have any surgery
• And one didn't answer the question

And in terms of the way they were living . . .

• 6 were living in their original role full time and had various intentions of progressing (none intended to stay that way)
• 16 were living most of the time in the original role, with two thirds (10) intending to switch to the other full time
• 2 had almost completed the transition, living most of the time in their new role
• and 23 (just under 50%) had already made a full time change.

So we had a sample in which the largest bulk was somewhere in the middle of a transition, half living as women all the time and more than half somewhere on the road to surgery.

It was originally hoped to examine how this group is distributed round the country, but 24 of the respondents evidently thought this too sensitive a question to answer.

All that could be drawn from half of the sample was that:

• 2 live in Scotland
• 2 in Wales
• 4 in the North and Midlands (Cheshire, Lancashire, West Midlands and Yorkshire)
• 1 down in Somerset
• 4 in London itself
• 12 in the home counties (Berkshire, Oxfordshire, Hertfordshire, Kent, Sussex, Cambridge, Norfolk)

However, as the author knows of five post operative transsexuals within 20 miles of her own doorstep in North Cheshire, it should be stressed that no conclusions can be drawn from this part of the analysis, other than that perhaps many transsexuals are excessively paranoid about being recognised.

Next we examined the age distribution of the sample and found that:

• 8 are in their twenties
• 15 in their thirties (nine over 35 and the biggest single number aged 38 for some reason)
• 10 in their forties
• 11in their fifties, and
• 5 in their sixties.

So next we wanted to know whether there was any pattern concerning the ages of our sample when they recall that their first intimations of being 'different' occurred.

In fact the ages when the respondents first said that they'd had a general feeling varied from 2 to 43!

This is illustrated graphically below and the results are deliberately broken down into what might be called the young transsexuals and the more mature group, as it has often been suggested that there are material differences between these.

As for when this became a definite conviction . . .

Well, here the spread was MUCH wider :

And once again we've also presented the results graphically with the two age groups distinguished.

So we found 50% of our group saying that they were getting very sure about what they felt before reaching adulthood and over 30% of the rest getting to same conclusion in their 20's and thirties.

More importantly, this sample showed quite a smooth distribution within age groups, no matter how we chose to aggregate it, which would seem to cast a lot of doubt over the belief that there are two sorts of transsexuals, distinguished by the age when they labelled themselves.

And if we look back at how early those first intimations were for the under thirties then, yes, 5 of the 7 did report recollections in the first 2-7 years, but equally the other two (in that admittedly tiny sample) didn't have those thoughts till their teens and later. In other words a quarter of our transsexuals who presented early in life didn't actually perceive their dysphoria until mid or late teens, just like our so-called late-onset group.

Of course, many researchers have done their counting based on the age when their clients sought professional assistance . . . which could be rather like saying that nobody seemed to ask for heart transplants before the late sixties . . . and this is examined further below . . . but the central assertion about many older transsexual subjects is that their condition isn't the same because they announced it later in life. However, if this were as clearcut as suggested then this imply that one could expect their first reported intimations (assuming they're being honest) to be correspondingly later too.

Fortunately the questionnaire provided the raw data from which the computer could be queried to check this. (Figure 4 below)

Again, it should be stressed that we are looking at the gap between the age when they reported what we called a general feeling and the age when they felt definite about it and deliberately ignoring the age when they actually joined a professional's client list. The first thing we therefore did was to get the computer to chart the relation between the age when that definite feeling was expressed and the number of years since the person said they first felt something and the result was a quite a consistent tendency for the gap to widen in line with the individual's age, indicating that in the majority of cases a late life decision is actually accompanied by a childhood feeling, irrespective of age.

Of course, in fairness there is no way of knowing whether the older subjects were all having false memories to suit their circumstances and it was a pity that we had to content ourselves with a sample of fifty subjects rather than five hundred, however with so many possible social and circumstantial factors able to affect each person's choice of when to publicly acknowledge their problem (particularly for those who faced those problems thirty or more years ago), this does seem to suggest one more reason to doubt the value of labelling people arbitrarily as early-onset or late-onset and implying a clinical significance for such labels.

What we then went on to find very interesting is that if you try the same technique to chart the gestation period for feelings against the subject's actual age then there is no pattern at all. ie. Among those in their twenties there is as big a scatter in the time those feelings took to develop (from vague to definite) as there is in the thirties, forties and beyond.

It simply seems to be a truism that the young transsexuals formed more definite decisions at a younger age. We just haven't yet met the ones who are going to take longer.

But, if we're to be healthily cynical for a while then the next question that pops into mind is whether there is some popular phenomenon at work. Has greater publicity and the greater awareness of the condition simply encouraged a glut of wannabe's?

Approaching this from another direction, we wondered whether if we were to use the current age of the respondents to put a date on when they said they were definite about their dysphoria, then would this show a peak (or peaks)? And is there a difference between the over 30's and their younger contemporaries in this respect? Also, is it different if we use the year when they first actually sought treatment?

To examine this we used the reference date that everybody has used before and which we discounted in the previous analysis. ie. When did our sample first present for treatment? And in fact we were not really surprised to see nothing before 1967 and then a steady rise in the 80's, a sudden doubling in annual rate in the 90's, and a relentless rise since then. Availability begets demand, of course. Naturally, since many of the younger transsexuals weren't even born before 1967, we've not in this case broken down the components of the graph according to age

But if we look at the year when our sample say that they first felt definite about their gender being wrong, it's an entirely different picture, spread so thinly that a graph is the only way to show it.

The blips, in fact, seem to correspond with periods when there was a lot of publicity and notice also that by charting the over 30's and the under 30's separately we can see that it isn't the sudden arrival of the younger group causing the peaks, but the over 30's.

But this brings us back again to the question of whether the older subjects got their convictions any later than the youngsters, who are a naturally distorted sample anyway? In fact, examining the age when the respondents said that they arrived at a definite conviction about themselves and plotting this against their age now, indicates that there is no pattern at all. ie Across all ages, there were people in our sample who arrived at their conclusion early in life and those who arrived at it only recently, with just as many in-between (Figure 7)

What you can see here is that the age of the subject (along the bottom) is no predictor of the age when they say they definitely believed or wished themselves to be a woman (the vertical axis). It will, of course, be interesting to see if this distribution changes in the next thirty years or so. With a greater public awareness and sympathy toward the subject, and with the availability of more and more professional help, will the phenomenon of the late decider diminish or disappear altogether, or will the pattern remain as seemingly random as it appears?

At this, and aware that there were so many other questions that could be probed from the same data we decided however to move on . . .

The next thing we were interested to know is how our sample were employed . . . were a significant number really out of work and how much did they earn? How well educated are they and what sort of work do they do? We started with the educational qualifications of the sample group (of 49) and how they were employed.

In other words the suggestion that transsexuals are unemployable and cost the state to keep them or that they have to resort to prostitution to support themselves was simply not borne out by the facts. Just out of further interest, only one of the unemployed was post operative, two were actually waiting for surgery, and the other four were not yet decided.

The actual breakdown is shown below.

The next question to come to mind was how much our sample earned...

Of course, bearing in mind that our sample are all people now making their way in life as women, the figures seem to speak more about our society as a whole than the earning prospects of transsexuals specifically.

And what work do they do?

And where do they do it?

And what industry are they in?

 
Next, we turned our attention to our respondents' partnerships and sexuality.

Dealing with the partnerships first . . .

And, equally importantly, what sort of partnerships did they seek?

And did they enjoy sex in their present role? (Ten people didn't reply to this)

How many of them had children?

6 had just one, 6 had two, and seven had more than that, including one who'd had five! (leading to the mischievous speculation that in that last case it might have been the wife who suggested surgery!)

Incidentally, from the nineteen with children, 16 were able to see them regularly and just three were not. We couldn't find any pattern in the age of the parent or the children, although there's not much to be deduced from a sample of three in any case!

Looking closer at the group who had no children, we in fact found that there was just one person under 35 with children, and in that case only one child. Assuming in this case that the younger respondents, growing up with less pressure to marry and have children could be considered different from their elder contemporaries we in fact separated out the nine (15%) of our sample aged thirty-four or under, and then found that we were left with 19 over 35's with children and 21 without ... an almost even split.

With the aid of the computer we were also able to deduce how old they were when the eldest and youngest children were born, and how these events in their lives stand in relation to their age when they first sought treatment . .

It's interesting to note that it's certainly not unknown for children to be conceived well after the start of treatment (in one case 5 years after) and nine of our sample were starting treatment within the childhood of the youngest or only child, . . . eight of them before the child's seventh birthday. (In all three graphs by the way, the X axis is the number of elapsed years from the child's birth to treatment and the Y axis counts the incidence.)

The number of years over which our respondents were having children is also quite interesting, and a closer look revealed that the 2-3 child families were produced in the shortest interval possible.

Having looked at the respondents' own children, we then also wondered about their own childhoods. Was there anything that stood out in terms of peer order?

There were just nine who had no brothers or sisters at all. (ie 40 had one or the other)

• Sixteen only had sisters
• Ten only had brothers
• Fourteen had both brothers and sisters

. . . Nothing conclusive here

• Of the thirty with sisters (ie 75% of the 40), 18 had just one, 7 had two, 4 had three and 1 had four
• Of the twenty-four with brothers (60% of the 40), 18 had just one, 4 had two and 2 had three

. . . Nothing conclusive here, either

Of the 40 with brothers or sisters, 17 were not the oldest child (ie 23 were the eldest)

• Ten of those 17 were junior to one or more elder brothers
• Twelve of the 17 were junior to one or more elder sisters
• (Some were obviously junior to one or more of each)
• Eight of the 17 were the youngest outright
• (so nine were somewhere in the middle)

Well, that's slightly more interesting because in our group of 49, 32 (23+9) were either the eldest or only child, but even there we're only talking of 65%. Overall, however, given the size of our sample it would be inappropriate to attach much significance to these results other than to suggest that, at least, there would not appear to be much evidence of a developmental factor such as this influencing the manifestation of gender dysphoria.

Next we were interested in the group's religious beliefs..

We also asked whether their church knew about their position and (if so) what sort of reaction or acceptance there was. For some reason this was a question that many simply failed to reply to.

This suggests that many of those who said they were C of E or Roman Catholicare therefore not what would be classed as practising ones, which of course makes the sample no different to society as a whole.

Next, were our sample happy and fit? And, if not, why?

First, were they in generally good health and, if not, could the ill health be attributed to gender treatment?

And, were they generally happy?

And, irrespective of whether Yes or No, what were the factors causing any unhappiness?

Seven of the fifteen blaming their present gender role cited this as the sole reason for being unhappy and in all but one of the remainder of the cases,it was combined with partner or family problems, which were themselves rarely cited alone. There were five instances where three causes were given, sevencombinations of two problems and thirteen respondents gave only one reason. Remember again that seven of these were simply blaming their GD.

In all, therefore, 24 listed no causes of unhappiness and 25 gave 1, 2 or 3 reasons.

Of the 25 listing problems, incidentally, four of them were post operative (out of 7 post operative cases in the study), only one was waiting for surgery, eight came from the 21 awaiting referral, and ten (the biggest proportion) came from the 14 who haven't hade their mind up yet.

Rather disturbingly, three of the four unhappy post-operative cases listed clinical depression, joined in two of those cases by a problem with their surgery and a partner or family problem.

We suspected, however, that simply asking the question once and so directly might not give a complete picture, so in the second part of the survey we included some questions targeted at the individual's personal image, acceptance and relationships . . as they perceive these things.

To begin with, we'll consider the questions about negative body features,where options were given to tick up to nine of what were thought to be the most commonly voiced problems

The first shock was how many of the respondents listed a lot of these together. . .

So what were the commonest physical problems among the 40 that listed some?

Now, one of the things we found intriguing was that although 90% of the sample were 5ft 6in or over (only three people being less than that), height was actually a long way down the list of physical problems, which were dominated by voice and hair issues. The hair problems were not restricted to the older sample. 2 of the seven under-thirties were in there too.

And we wondered whether the voice problems diminished with the progress of time? It certainly wasn't age related, as the proportion was about 50% in each age group but there was a distinct pattern in terms of where the people were on the road to surgery.

Those waiting to be referred for or not yet decided upon surgery are also those most likely to be in the early stages of treatment, and presumably speech therapy had not been started or had much time to take effect. Those further down the path to reassignment made up just 12% of the number reporting problems with their voice, and a mere 6% of the whole group.

We also looked at height and weight, wanting to know whether there was anything to support the widespread belief that make to female transsexuals are all heavily built.

(2 did not give their weight and 2 did not give their height) For our overseas visitors 1 stone=14 pounds, 1lb.is approximately 0.5kg.

When we looked at the relationship between height and weight, however, we found something quite interesting. First we noted that the shortest was just under 10 stone and that, overall, although the ratio between weight (in lbs)and height (in inches) varied from 1.8 to 3.2 (with the majority between 2.2 and 2.8), the actual range at each height was quite large, so that we see a band of weight that is almost independent of height. (The X axis represents height in inches and the Y axis plots corresponding weight in lbs)

Next, what about the benefits and consequences of treatment as seen by the person on the receiving end? In this instance, we actually choose to ask the pre- operative and post-operative groups different but overlapping sets of questions, and so although the questions are very often the same. The results are presented separately and the reader can combine them if desired.

Starting with the larger unoperated group (sample size: 42, nil replies: 12)

And for the much smaller postoperative group (sample size: 7, nil replies: 1)

Lastly, we were interested to know how well our sample was looked after by the medical and psychiatric profession.

What sort of drugs are they taking and in what doses? How often is their blood pressure checked? How far do they have to travel for counselling?

Taking these in reverse order . . .

We also asked whether the postoperative group had follow-up counselling available to them, and whether they used it. Four of the five who replied said that it was, but only two of those used it.

When it came to blood pressure checks, 31 replied :

So we know that about 25% of our sample are having their blood pressure checked at least occasionally.

And, finally what sort of hormone regime are they following?

Well, in fact there weren't actually any great surprises here as might have been feared, although the data was very difficult to analyse on account of the various ways people to chose to express what they take. A statement like two a day obviously wasn't very helpful and this is therefore a part of the questionnaire that could benefit from careful redesign in the future

8 people were taking the anti-androgen Cyproterone Acetate at 100mg daily (incredibly, one after surgery, the other seven waiting for surgery or to be referred for it) and one of the pre-referred group was taking Cyprostat (50mg).

There are also, 2 Estraderm users (1 waiting for surgery, the other undecided), 1 post-op Duphaston taker, two Cyclogest users (1 post-op, 1 waiting for surgical referral) and 2 using Spironolactone (both waiting for a referral).

Quite a medicine chest, and not a lot of apparent consistency. Two of the post operative group were taking nothing at all (possibly unaware of the attendant health risks), and one of them was taking a testosterone suppressant.

The last question therefore had to be, "Who is determining these doses?"

There were also a lot of people who didn't answer this at all.

In conclusion

As stated at the outset, the only reservation we had about the survey's results was that we had a smaller sample than we would have liked. Ideally, we would have had a hundred or more returned questionnaires and, as a result, the scope to draw greater comparisons with other research (which is so often itself subject to criticism about sample sizes). It is particularly important to have a substantial sample when the data seems to indicate that there are few real patterns. ie. It is paradoxically easier to feel that you've got somewhere to validly draw a line (and prove its significance statistically) than to confidently state that there is no pattern in the data at all when there are few points to plot.

Yet trendlessness is what the data seems to suggest in many cases. ie. Aside from the label that groups them, the 49 M to F transsexual members of the Gender Trust surveyed over nine months from December 1993 to August 1994 otherwise appear to be as mixed a group of people as you would find by picking any same-gendered group of citizens at random. They have a wide variety of jobs, and hold onto them to make their own way in life and, in spite of an unsurprising catalogue of problems directly related to their change, the most noticeable statistic of all is that none of them wish to turn the clock back on their change of role or surgery.

Another clear fact that emerges is that transsexuals have sex lives even if the preferences and solutions adopted might vary widely. Equally, almost 40% of our sample had families of their own, which most of them are also still able to see and love . . . emphasising the point perhaps that so many have tried (and to a great degree succeeded) in following society's expectations before asserting their identities.

However, of course, it is tempting to go on and make more observations for the simple reason that so much unsupportable folklore has existed for so long and been used to stigmatise a group of people who merely ask to be understood and respected for their feelings and conviction. With more data perhaps we could set out to demolish the myths altogether, but then that is why this has to be regarded as a preliminary analysis. We've posed the questions, and to a great extent we've also vindicated the reason for doing so and found tantalising indications about the answers. What has to come next, however, is an effort to increase the numbers.

The computer-based techniques used to analyse the data have been a great success too, underlining the sad fact that it would have been as easy to collate five hundred responses as it was to handle fifty. In particular, some questions that suggested themselves in the middle of the actual analysis could only be effectively answered by inferring the necessary data from unrelated questions, and the ability to graph data in seconds encouraged a speculative approach to looking for patterns as they came to mind and freeing the author to indulge each new idea that came to mind, thus expanding the survey far beyond the scope of the basic questions it was designed to answer.

Acknowledgements.

The author is indebted to Alice Purnell for arranging the distribution of questionnaires and for ensuring that the responses were passed on.

Thanks are also due to Jane Lomas, whose help with the thankless task of data entry made the rest so easy, and whose interest in the subject suggested somany new and interesting questions to pursue.