ARTICLES Patient Satisfaction with Sex Re-assignment Surgery in New South Wales, Australia Fran Collyer and Catherine Heal Department of Social Work, Social Policy and Sociology, Private Practice
An evaluation of the effect of sex re-assignment surgery on a group ofpatients attending a private clinic in Sydney, Australia. Fifty-seven patients who underwentfull male-to:{emale sex re-assignment surgery between 1987 and 2000 completed a satisfaction suroey. Severalfactors that might influence the extent ofsatisfaction with surgical outcome were explored, including age, work status, social It{e, and the appearance andfunction ~{the new genitalia. Patients reported significantly improved social and personal satiifaction following surgery, compared with five years previously. The study challenges outcomesfrom preViously reported studies with regard to the age ofpatients at the time of surgery, and the finding that from the patient's perspective, there is nofundamental association between a successful surgical outcome and a satisfactory post-operative life experience. Key words: Patient Satisfaction; Sex Re-assignment Surgery
Surgical sex re-assignment of transsexual individuals diagnosed with gender dysphoria has been performed in Australia since about the late 1950s. The interest in sex re-assignment surgery has led to a number of papers published in specialised journals about the various surgical techniques and potential complications (Edgerton, 1984). It has also led to studies concerning the outcomes of surgery from a functional and psychological point of view (Lundstrom et al., 1984; Walters & Ross, 1986). Since the 1970s, an increasing interest has been shown in the social context of transsexualism and surgical reassignment (Brake, 1976; Raymond, 1979; Kessler & McKenna, 1978; Hoenig, Kenna & Yond, 1970; Bolin, 1988; Hooley, 1997; Collyer, 1994). This literature places the transsexual within a complex cultural setting, where gender and sexual identity are not biologically given but actively formed, resisted, challenged and sometimes even transmuted. As Bolin insists: Transsexuals are involved in a unique transition in which an 'ascribed' or inherited status is disavowed and a new status is coveted. They violate one of the most hasic tenets of society, that gender is invariant and cannot be 'achieved' or 'acqUired' 0988:8).
empirical studies demonstrate that transsexuals are socially heterogeneous, sharing little but the process of gender change and the associated medical experiences (Perkins, 1994; Collyer, 1994). This same body of literature situates sex reassignment surgery within the powerful (and similarly complex) institutions of medicine and law. Much is offered in the way of critique of these institutions, with regard to the legal ramifications for transsexual individuals (Samuels, 1983; Finlay, 1997) and more particularly with regard to the potentially negative impact on transsexuals of the medical use of psychiatric categories ( Mirowsky & Ross, 1989), therapies and treatments, and its power to define and regulate sexuality (Vance, 1991:880; Hooley, 1997; Collyer, 1994). Of all modern therapies and interventions, sex reassignment surgery has probably been one of the most contentious, causing considerable consternation both within and outside the medical profeSSion. In part this is because of the recognition that, through surgical intervention, the profession is a crucial participant in a process which is widely regarded as "natural" and outside their legitimate profeSSional domain. In a study of cosmetic and reconstructive surgery it was found that surgeons:
Although some of this literature presupposes transsexuals to be part of a "community" with shared lifestyles and values (Raymond, 1979),
... uphold normative attitudes and activities for sex categories and, hence, become co-participants in the accomplishment ofgender. In addition, surgeons
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Fran Collyer and Catherme Heal
act as technological facilitators of gender's accomplishment and as cultural gatekeepers in the fine tuning ofgender's presentation. Thus, cosmetic surgery emerges as an institutional supportfor 'dolnl( gender' (Dull & West, 199168). .
Other reasons for its contentious status can also be found. Some members of the profession perceive transsexualism to be a "delusion of psychotic proportions", and consequently sex reassignment surgery to be an inappropriate and ineffective therapeutic response (as reported by Burnard & Ross, 1986:55). Outside the profession, some individuals take issue with sex re-assignment on ethical and religious grounds, seeing it as challenging Christian values (Tonti-Filippini, 1989; O'Donovan, 1984), while others object on political grounds, regarding sex re-assignment surgery as a patriarchal conspiracy (Raymond, 1979). These views are not widely held, however, and surgical sex re-assignment has gained increasing acceptance in the management of male-to-female gender dysphoria. Although empirical studies show mixed results, there is mounting evidence that surgery offers greater benefits than alternative treatments (Walters, Kennedy, & Ross, 1986:148-9; Walters, 1997:148). Such studies focus variously on the social, psychological and technical outcomes of surgery. Increasingly, it has become recognised that successful technical outcomes, while fundamental, are not sufficient to ensure that patients will be completely satisfied with the overall outcome. For example, in a study of 22 patients from a Melbourne clinic, 80% reported "a good or satisfactory outcome after surgery", despite the fact that 35% were dissatisfied with the dimension of the vagina (Walters, Kennedy & Ross, 1986:147, 149). Such studies support the emerging view that psychological and social factors playas significant a role as technical outcomes (Lindemalm, Korlin, & Uddernberg, 1986; Lundstrom, Pauly & Walinder, 1984; Haertsch & Heal, 1997). Despite this insight, there are few studies that seek to systematically investigate the relationship between the technical results of surgery and overall levels of patient satisfaction. This study seeks to remedy this situation by exploring a range of factors that have the potential to shape the patient experience.
The patient satisfaction survey Over a period of two years, 57 patients who had undergone a full surgical re-assignment from male
10
to female, and had attended a clinic in Sydney, completed a self-administered questionnaire. The aim of the questionnaire was to evaluate the patient's satisfaction with the cosmetic and functional aspects of surgery as well as to assess the psychosocial impact of surgery and the reassignment process upon their lives. Questionnaire-based surveys have become increasingly popular as a means for hospitals and other health services to assess the quality of the care being provided. Many practitioners and researchers consider it essential that information about services be obtained from patients, and that this information be systematically collected and analysed. Thus, it is not surprising that questionnaires have become essential methodological tools (Rose & Gershuny, 1995). Compared with interviews and focus groups, questionnaires are efficient, easily administered, and facilitate generalisation from sample to population (Churton, 2000:199-200). In our questionnaire, patients were asked how the surgery had affected them both socially and physically, while some demographic and employment information was also sought. For example, patients were asked about their occupational status five years prior to surgery, at the time of surgery, and currently. Patients were also asked a series of questions about their social life (before and after surgery), their friendships and relationships, their financial circumstances, and several questions about sexual function and satisfaction (before and after surgery). They were also encouraged to renect on their decision to have surgery. The questionnaire was four pages long, with large print and widely-spaced questions. There were 20 questions and all were phrased in simple "everyday" language given the wide educational range of the patient group. Most questions were multiple-choice (using a scale of three to six categories) requiring the respondent to circle the most appropriate answer. Two pieces of information were considered crucial to this study: (a) the patient's level of satisfaction with their new genitalia; and (b) whether the decision to have surgery has been, in retrospect, the "right choice". To collect this information, a forced-choice question was used to introduce the subject, but spaces were made available for additional qualitative comments. Respondents were also encouraged to make additional comments on the final page (which was Australian Journal of Primary Health -
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blank) or attach additional pages. Sixty-eight per cent (39/57) offered qualitative comments to the first of these questions, 77% (44/57) to the second, and 33% 09/57) attached additional and unsolicited comments to the questionnaire, with several participants enthusiastically writing between two and three pages. Despite their popularity, a number of criticisms have been made of the use of patient surveys. Draper and Hill 0996:458) have found that the concept of "patient satisfaction" is variable over time and between individuals; and Williams 0994: 514) reports that these surveys tend to overestimate the level of satisfaction with a service or program as attention is paid to general rather than specific issues. Questionnaires have also been criticised as providing superficial or inaccurate data due to the imposition of the researcher's world view on question construction and the narrow range of choice in response to questions (Neuman, 2000:260). In our study, we used four techniques to overcome the limitations of the survey approach. First of all, question wording was kept consistent with the form of language used by most patients to minimise misunderstanding. Secondly, to limit potential ambiguity in the use of the concept of "satisfaction", several similar questions were used to elicit essential information rather than relying on answers to one question. Thirdly, to ensure that satisfaction was not overestimated, questions were made specific rather than general; for example, rather than asking whether patients were satisfied with their surgery, we asked, "How satisfied are you with the appearance achieved by surgery of your vagina and genital area?" Fourthly, and perhaps most importantly, while we recognised that in-depth interviews might be a better technique for obtaining accurate information about attitudes and experiences, we were very concerned about further invading the privacy of this over-researched yet tiny section of the population. Thus we used a self-administered questionnaire that offered a small, but important, sense of anonymity for participants. These four techniques helped to ensure the validity of our data. While most selfadministered questionnaires appear to yield only superficial information about responses, we believe our data is both robust and accurate because it results from a combination of an anonymous questionnaire and the professional and friendly Australian Journal of Primary Health -
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rappon that had been built over several years between patients and staff at the clinic.
The population from which the study sample was drawn Over the period of 1988-July 2000 a total of 223 patients underwent full male-to-female sex reassignment surgery at the Sydney clinic. Referral to the clinic was on the basis of all patients haVing been hormonally re-assigned with oestrogen therapy prior to surgery, with a medical report to that effect from their treating endocrinologist or medical practitioner. Two independent psychiatric reports in favour of re-assignment surgery were mandatory. In addition, a pre-operative interview with both the surgeon and nurse consultant was conducted with each patient to confirm voluntary informed consent. All patients were expected to have lived as a woman on a day-to-day basis for a reasonable length of time to ensure that they were able to understand and appreciate many of the social, legal, and interpersonal implications of a permanent change in gender status. The exact length of this pre-operative lifestyle trial was negotiated with the primaly assessing psychiatrist. Table I: Number of patients per year who underwent full female-to-male sex re-assignment surgery at the Sydney clinic Year to July 2000
No. Patients
1988 1989
8 10 22
1990
1991 1992 1993 1994 1995 1996 1997 1998 1999
30 11
22 33 12 19
14 17 17 8 223
The Sample Between December 1997 and June 2000 questionnaires were given or mailed to 85 patients who had recently attended the clinic and for whom we had reliable contact addresses. Fifty-seven patients completed this questionnaire. As can be seen from Table 1, this represents a response rate of 57/85 or 67%. The survey sample represents 57/223 (26%) of the surgically re-assigned patients 11
Fran Collper and Catherine Heal
at the Sydney clinic. The response rate to the questionnaire may be considered an excellent result given the well-documented difficulties in maintaining contact with this geographically and socially mobile patient group (Eldh, Berg, & Gustafsson, 1997). The participating patients in our study were all past patients who had had a complete surgical reassignment and had either returned to the clinic for additional treatment andlor had provided us with permanent addresses for themselves or a family member. All members of this group were mailed or hand-delivered a questionnaire for selfadministration. The survey sample of patients may not be representative of all transgender patients who have pursued surgery. This sample has been drawn from a private clinic in Sydney, all of whom had surgery on a "private fee" basis with only a small reimbursement from the Australian Medicare system. Consequently, the total patient sample reflects only those who have sufficient economic means or exceptional support from family or significant others. The survey sample is also to some extent self-selective, as it contains patients who could be contacted and also agreed to participate in the survey. This self-selection may have partially inflated the satisfaction rate within our sample, with dissatisfied patients deciding not to pursue contact with the clinic and consequently not being given a questionnaire.
Data Analysis A statistical computer program (SAS) was used to analyse the quantitative survey data. All coding was performed by one individual to ensure consistency, and statistical manipulation was kept to a minimum given the small sample and the need to maintain statistical validity. The qualitative data, which derived from the two open questions and the invitation to participants to comment further, was analysed using qualitative analytic techniques. The methodological framework which underpins qualitative analysis is based on the view that the selection, ordering and displaying of text necessarily involves some subjectivity on the part of the researcher and will be influenced by the theoretical framework. Nevertheless, this need not detract from the value or validity of the analysis, providing the analytical process is as open as 12
possible (de Vaus, 2001:251) and a critical, reflexive approach is maintained (Seale, 1999:158). In this study, the goal of analysis was to assemble the qualitative data into a coherent picture that not only authentically describes the experience of transsexuals undergoing sex re-assignment, but offers a plausible (even if partial and preliminary) explanation concerning the relationship between clinical outcome and overall patient satisfaction.
Results and Discussion Internationally, there have been various attempts to ascertain the general level of satisfaction with sex re-assignment surgery, although a consensus has not been reached over the appropriate means to assess efficacy in this specialty area (Walters et al., 1986:144). Nevertheless, a number of international studies indicate that between 10-15% of patients regret re-assignment (Eldh et al., 1997). In Australia there have been no systematic evaluations of patient outcomes by either government or private agencies (Lowe, 1996). In one Australian study, the level of dissatisfaction was estimated to be 26% of patients (Perkins, 1994). It should be noted, however, that the Perkins survey was small 08 patients), included patients from several surgeries and geographical areas, did not distinguish been clinical, psychological, or social outcomes, and drew many of its respondents from a community refuge centre. Consequently, its sample is heavily biased toward persons experiencing ongoing personal trauma. In contrast, our total patient group is skewed toward persons with adequate financial means (which is suggestive of a relatively stable lifestyle), and toward those who have agreed to ongoing contact with the medical profession. Thus the actual level of satisfaction with sex re-assignment surgery in the Australian population may at best be estimated as falling somewhere between the numbers estimated by Perkins and those of our study. Overall, patients reported that the surgery had brought with it an improvement in their lives. Eighty-six per cent (49/57) stated that they were much more satisfied with their lives at the time of the survey than they were 5 years prior to surgery; 9% (5157) of patients reported a little more satisfaction; 4% (2/57) of patients felt their lives were much the same; and 2% (157) reported a little less satisfaction. None reported "much less satisfaction" . Australian Journal of Primary Health -
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Patient Satisfaction wi/b Sex Re~asslgll1/lent Surgery 111 New Soutb Wales. Australia
Patients were asked whether their decision to pursue surgery had been the "right one for them". Overall, 96% (55/57) agreed their decision had been "right". As discussed above, patients were given space on the questionnaire to provide further comments about their decision to pursue surgery. These qualitative responses were extremely positive, given that only two patients expressed any ambivalence about their decision. Some patients suggested that the decision had been a critical one, which had changed their lives dramatically. For example, one patient stated, "I am more than happy with the surgery. I would go through it again. lowe my life to Dr X" (10 2). Similarly another patient responded, "The confidence and freedom I now feel has given me a complete 360 degree turn in my life" (ID 5). Several respondents emphasised the impact sex re-assignment had on the more intangible aspects of their lives. For example one participant stated that, "Spiritually and emotionally I am very satisfied with my decision" (ID 55), while another responded with, "I just can't find the right words to say how grateful I am ... since surgery I have found the peace within my soul ... " (ID 34). Prior to surgery, all patients are evaluated by a psychiatrist to assess whether they have an understanding of the limitations and aims of the surgery (Haertsch & Heal, 1997:172). In part, this is based on the view that individuals with reasonable and realistic expectations of what can be achieved by the surgery itself are less likely to be disappointed. Our study indicated that this "message" had been communicated to patients, as several participants demonstrated a philosophical and realistic approach to the surgery. The unsolicited comments of two participants offer good examples of this: To he denied surgery would hal!e heen au:[ul as it was I!ital/or my gender to he congruent with my genitalia and I would bal!e walked ol!er bot coals/or tbe surgery that aligned my body with my mind. It's important to note tbat tbe psycbological and social factors on which life is embedded have little to do with surgery - my happiness or sadness does not depend on surgery but my own psychological adjustment (ID 7). Surgery does not change people's life it only changes the shape 0/ their genitals and anyone who is looking /01' a magic change to their lives will be sadly disappointed as change is a matter o/mind not surgery (10 13).
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All survey data will contain ambivalent or contradictory responses, and ours does not differ. In this study there was only one problematic response, and this was to the question regarding whether the patient's decision to have surgery had been right for them. As noted above, 55/57 responded that their decision had been right, and only one patient clearly dissented from this. Another patient however, ticked neither box and wrote "yes-no-yes":
If I bad known all tbe beartache I would cause. being married at the time ... I would not hal!e had surgery ... I may have thought twice ... But as I cannot turn back the hands a/time ... and I hal!e done tbis " Ilo/Ie my new way of life (10 45). Our interpretation of this response is to accept this as an accurate reflection of this individual's views. We recognise that there are instances where individuals are ambivalent and vary between two positions. Indeed, it is normal for opinions, beliefs and attitudes to change over time and from context to context (Foddy, 1993:4). This response also reminds us that the decision to proceed with sex re-assignment surgery can have very real ramifications for individuals other than the patient (such as their children and former spouses). Friendships and social life In order to ascertain why some patients are more satisfied with surgery and its outcome, a number of factors were explored. These included friendships and social life, employment, the impact of surgery on a patient's financial circumstances, age, and surgical outcome. Patients were asked to compare their social Jives before and after surgery. The results of this comparison are provided in Table 2. Many patients reported an improvement in the quality of their friendships after surgery. Only one patient (2%) reported a negative change in her social life since surgery, 46% (261 57) reported no significant changes, and 53% (30/ 57) reported a positive change. Table 2: Patient Satisfaction with Quality of Friendships Before Surgery
After Surgery
insufficient or unsatisfying friendships
46% (26)'
sufficient and satisfying friendships
28%
16)
44% (25)
sufficient and very rewarding friendship
26% (15)
51% (29)
5% (3)
'n= 57
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Fran ColIl'er and Catherine Heal
The fact that 53% of the patients reported a positive change in the quality of their social lives is significant. Criticisms of surgical sex reassignment have often been based on an uncertainty about the social and psychological impact of surgery (Giles, 1989:296-99), Among our sample there is strong evidence from the patient's perspective that the surgical intervention has had a positive social effect. The data also reveals an association between a patient's satisfaction with their social life and surgical outcome. Patients who reported that their friendships are currently unsatisfactory are also more likely to report dissatisfaction with surgical outcome. Sixty-seven per cent of those who report friendships are insufficient or unsatisfactory are also reporting the lowest levels of satisfaction with surgery, while only 24% of those with more satisfacwry friendships are reporting low levels of surgical satisfaction. A similar association occurs between satisfaction with surgical outcome and a patient's overall satisfaction with life. Patients who were more satisfied with their lives generally were also much more likely to be satisfied with the surgical outcome. Thirty-three per cent (5) of the patients who were least satisfied with the surgery were also unsatisfied with their lives generally, while 100% of the patients who were highly satisfied with the surgical outcome were also much more satisfied with their lives generally. Patients were asked for their opinion about whether it was the surgery itself that had contributed to any improvement in their social lives. The majority of patients believed there was a connection, with 49% (28/57) stating that surgery had contributed "a great deal", 32% (18157) "a little", 11% (6/57) "no real impact", and 9% (5/57) reporting "not at all". Qualitative comments suggest that for many patients, these improvements in their social lives result from an increase in self-esteem and self-confidence associated with the completion of the gender transition process through sex reassignment surgery: My decision to proceed with surgery was based on my appearance to myself. I suffered immense paranoia pre-operativelv when clothed, toileting and hathing. I am now more at ease with myselfand 100% satisfied with my whole being ... my mind, emotions und body are the same (ID 56) Halling been neitber male nor female I always tbougbt 0/ myselfas/emule, the surget}' has made me
14
much more confident in myselfand my friends halle commented on tbis (lD 46).
Employment and Finances Patients were asked about their experience with maintaining employment over the period of gender transition. A comparison was made of employment status five years prior to surgery with employment at the time of the survey. The results are displayed in Table 3. For 9% (5/57) there was a positive change (e.g., obtaining a job after a period of unemployment), and for 79% (44/57) there was no significant change, but 13% (7/57) experienced a negative change in their employment status. These results suggest that one group experienced a deterioration of their circumstances, particularly for those who became a member of the pensioner group. This last category grew from 9% to 23%. In the study by Eldh et al. 0997:45) it was found that those on disability pensions prior to surgery usually remain in the same state after surgery. In our group, the five who were on a pension prior to surgery also remained on a pension. They were joined by one who had previously been unemployed, and by two who were over 55 years at the time of surgery and had moved onto aged pensions by the time of the survey. In regard to the other five new pensioners, four were previously working and one had had an independent income. One of those previously employed injured her back at work and for this reason was placed on a disability pension. This leaves a group of three individuals who were younger [han 55 at the time of surgery but moved out of the workforce onto pensions after surgery. It is this group of individuals (3/57 or 5%) that appear to have suffered a negative impact on their employment status as a consequence of surgery or the related process of gender re-assignment. However, to place this in perspective, this group (5%) is smaller than the group whose circumstances improved after surgery (9%), and in total, 67% of the sample are currently in employment. This is easily comparable with the number of women working in the wider population, suggesting that, in general, sex re-assignment does not have a negative impact on employment prospects. Patients were asked whether they believed surgical re-assignment had contributed to a change in their financial circumstances. For 11% (6/57)
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Patient Satisfactioll with Sex Re-assignment Surgery in New South Wales, Australia
surgery had contributed "a great deal" to a financial improvement, for 7% (4/57) it had contributed "a little", for 28% 0 6/57) their financial circumstances were "unchanged", and for 54% (1) surgery had "not contributed at all" to any financial improvements. Several patients offered unsolicited comments that they had found the cost of surgery itself particularly onerous, one stating that "temporarily it put a big hole in my finances" (ID 12). Not unexpectedly, the surgery had the most negative impact on those already financially vulnerable (i.e., patients on pensions or unemployed), with 92% of this group finding the financial impact of surgery to be a negative one. This compared with only 80% of the working/ studying group finding the impact to be negative: While my income has not chanRedgmatly, tbe cost a/surgery plus ditJOrce has impacted significantly on my/inancial circumstances (ID 53).
The survey data suggests that there are connections between a patient's employment status and general satisfaction with their lives and their friendships. Slightly more of the patients who were working or studying at the time of the survey reported a high level of satisfaction with their lives than did those on pensions (89% compared with 77%). Patients' current employment status also appears related to satisfaction with social life, because 57% (25/44) of those who were working or studying reported an improvement in their friendships, compared with 38% (5/13) of those who are on pensions. This suggests either that those who are content with their social lives and their lives generally are more likely to be successful in sustaining employment, or that successful employment impacts positively on a patient's social life. Alternatively, these factors are interactive. Interestingly, the only patient who reported that surgery brought with it a negative change in their social life is on a disability pension. Work status also appears to be positively related to improvements in sexual satisfaction. Slightly more patients currently working or studying reported an improvement in sexual satisfaction since surgery (64% or 28/44, compared with 55% or 6/11). This finding supports the idea of a complex connection between social life, life satisfaction, sexual satisfaction, and employment status. It is expected that this association would
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be found in the wider population and is not unique to our group of patients. Age
Age is often considered an issue in male-to-female surgical re-assignment, given that the sooner gender transition is under way, the more chance there is of arresting the full development of masculine body characteristics (d. Lindemalm et al., 1987). Indeed, in a study by Lundstrom et al. (984), being under 30 years of age at the time of surgery was considered an essential prerequisite for a successful outcome. In our survey, however, age is not revealed as a particularly significant factor in shaping social outcome. There was some small association between age and overall satisfaction with life, with 92% of those in the 21-35 year age group reporting much more satisfaction with their lives since surgery, compared with 82% of those over 35 years of age. However, the age of patients at the time of surgery had no influence on whether they proposed a connection between surgery and improvements in their social life. Half the respondents of all ages reported that surgery had contributed a great deal to improvements in their social lives. Similarly, age at surgery is not a factor in whether or not the patients are more critical of the results achieved through surgery. Nor is there a difference between the age groups in regard to the number of problem areas reported. Age does, however, have some impact on the relationship between financial circumstance and surgery. The majority of patients (82%) stated that surgery did not contribute to any financial improvement in their situation; however, the group that reported a positive connection between these factors were patients who had been younger at the time of surgery. Twenty-five per cent of those who were under 35 years at the time of surgery indicated a positive effect compared with only 12% of those over 35 years. This finding is not unexpected, given that earlier surgery provides patients with more opportunities to pursue education or work retraining. Overall, the survey results suggest that surgery has a positive impact on transsexuals of all ages. Indeed, based on this data, there is no reason to restrict surgery to younger transsexuals provided the patients have reasonable expectations of the
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Table 3: Patient Employment Status Before Surgery
*
After Surgery
full-time employment
63% (36)*
53% (30)
part-time or casual employment
11%
14%
- total employment
74%
studying
11%
(6)
unemployed
2%
(1)
Pension (including disability and aged)
9%
(5)
(6)
My genitals only appear normalfrom front or with my legs together. If I sit with my legs spread or crosslegged there is not enough labia surrounding my vaginal opening. It gapes open and looks very unnatural (ID 36).
(8)
67% 4%
Some patients recognised that variation in appearance is a normal phenomenon. For example:
(2)
Perfectly happy with the appearance. My clitoris has migrated downwards and to the right over time, but I feel that this is a 'normal' variation (ID 6).
23% (13)
I didn't expect perfection, but a good approximation. I got if! After all, what is normal? Who inspects genital areas with a magnifying glass? No one I've ever known - me included. It all looks pretty good. Mum thinks so too! (m 38).
n= 57
likely outcome. In regard to financial circumstances, while transsexuals of all ages may adapt socially to their post-surgical condition, it is not surprising that younger transsexuals will be able to make more use of their newly-confident selves to improve their financial circumstances and employment prospects. In the words of two of the patients:
Although the majority of the patients were satisfied with the appearance of their genitals that had been achieved through surgery, it is important to ascertain the extent to which patients were satisfied with the function of their new genitalia. This information is illustrated in Table 4.
My only regret is that I waited so long (ID 38). Table 4: Functionality
I feel happier, more at peace with myself Ifeel I relate to people better as now I am complete. Both my children say I should have done it years ago (ID 1).
Surgical Outcome *
Patients were generally very satisfied with their surgical outcomes, with 91% (51/57) reporting satisfaction. Patients offered comments such as: I think it is great. I like the look of it. I don't know
ifyou could improve on what you haue done because I have not seen anybody else. But I do like mine (ID 50). Definitezy, my self-worth has improved, I love my new body and feel at peace with the world (ID 25).
These comments suggest that surgery has been an important "milestone" for many transsexuals, and that it has been a significant factor in assisting them to achieve a satisfactory life. As one patient commented: My ambition is to be as real as can be. In my decision to have surgery I believe I have achieved my ambition (ID 33).
Only 9% (6/57) stated that they were dissatisfied with the appearance of their new genitals. Some commented on this dissatisfaction: My vagina doesn't look normal (ID 21).
16
More orgasmic since surgery No change in orgasmic capacity Less orgasmic since surgery
22* 21 14
39% 37% 25%
More sexually satisfied since surgery No change in sexual satisfaction Less satisfied sexually since surgery
34 17 4
62% 31% 7%
n-57
In regard to the level of function achieved by surgery, it is clear that in our group most patients (62%) reported an increased level of sexual satisfaction since surgery. Indeed, 93% reported that their sexual satisfaction was better or unchanged since surgery. For some patients, sexual satisfaction was not necessarily accompanied by an increase in their level or quality of orgasms, but even here, 75% reported that their orgasms were the same or better since surgery. This is higher than the 55% of patients who reported they were sexually satisfied in the study by Eldh et al. 0997:42). A few patients commented on the problems of poor surgical outcome: My vagina is not the depth reqUired to accommodate an average-sized penis, which has caused mefeelings offear and inadequacy which I would like to have fixed (ID 5). Appearance is OK. It's function (or rather a total absence thereof) that bothers me (ID 18).
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Patient Satisfaction with Sex Re-assignment SurRer,; in New South Wales. Australia
Surgery was right for me; however, the fact that I have had two follow-ups and will need another following, (and that because ofthis I've had to wke a lot oftime offwork) and the pain and average results of the surgery, have le./i me with a rather jaundiced view of the whole process (ID 52).
For others, the lack of function is not an overwhelming problem:
It surprises even me that, notwithstanding all the trauma invollied and the lack offunction that was achieved, I would likely go through the procedure again in order to have my body conform most close~y with my mental gender OD 17). The decision for gender re-assignment surgery was,for me, both necessary and beneficial. Whatever other social or psychological issues I may experience certainly do not stem from my surgery or its outcome (m 14)
The issue was never about 'haVing sex' but one of making my outside appearance the same as my inner selfOD 54)
It has been suggested elsewhere that a good surgical result is fundamental to overall outcome, though it is emphasised that surgical result alone is not enough (Lindemalm et a1., 1986; Lundstrom et al., 1984). In this study we investigated whether surgical outcome is "fundamental" to a patient's overall satisfaction. For this purpose a surgical outcome scale was devised. Patients were classified into three groups-those reporting poor, fair, or excellent surgical outcomes. Outcome was scaled according to patient responses to a series of questions regarding the depth of their vagina, relative capacity for orgasm, straightness of urine flow, difficulty passing urine, pain or discomfort with sexual arousal, and the identification of problem areas with their genitalia. Using this scale, we found that patients who reported a high level of functionality were also likely to be very satisfied with the appearance of their genitals. For instance, 97% of patients obtaining a fair or excellent surgical outcome were satisfied with the appearance achieved by surgery, compared with 76% of those who obtained a poor outcome. Similarly, we found that a good surgical result is associated with a high level of general satisfaction with their lives since surgery. All 23 patients (100%) who reported an excellent surgical outcome also reported that their lives were now much more satisfying than they were prior to surgery. In addition, patients with a good surgical outcome were also more likely to report an increase in sexual satisfaction since surgery. What this data indicates, however, is that while the tendency is for a good surgical outcome to occur in association with generally high levels of patient satisfaction, we also find that even those with very poor surgical results may state that their lives are much more satisfactory since surgery:
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Still feel it was a good decision for me, four years post-op. It's true that on~y some of the henefits of the change actual~y came to pass, but some unexpected and quitepleasant advantages also an'ived. We should not expect too much from our gender change alone, lifestyle change seems to depend on how adept we are at bringing about the lifes~yle we seek (ID 22).
Such comments throw greater clarity on the relationship between surgical outcome and satisfaction. They suggest, contrary to other studies, that successful surgery is not fundamental to general satisfaction but rather one important factor that can assist in helping transsexuals achieve a generally more satistying life. This conclusion is supported by the fact that 12 of the 17 patients (24%) who reported a poor surgical result also expressed the belief that their lives were much more satisfactOly since surgery. Our study provided insights into some of the social factors that assist transsexuals to achieve a satisfactory life, including friendship networks and employment status. It also provided some insight~ into some of the socially created barriers, which make life more difficult for this group of peoplebarriers which cannot be eliminated through surgery. One of these barriers involves the legal system, which in many states continues to discriminate against transsexuals: Yes, absolute~y no regrets [about the sW'l5ery}. Yes, I had tried everything else and knew I could never be happy without it. The only cloud on my happiness is the lack oflegall'ecognition in WA and.federa/~y, the re-assignment process needs to be completed in law, only then can we put the past behind us (ID 32).
A second issue concerns body shape and size. The body has become an increasingly significant focus in modern western societies over the past few decades. The issue is generally seen as a particular problem for women, and one that is constructed, or at least promulgated by, the media (Malkin, Chrisler, & Wornian, 1999). Among transsexuals, body shape and size are fundamental to notions of maleness and femaleness, and studies 17
Fran Collyer and Catherine Heal
have found that this group shows more interest in body shape and size than do the rest of the population (Lewins, 1994:3). It is probably not surprising therefore that Lundstrom et al. (984) found that one of the prerequisites for a good outcome after surgery is the presence of a body build appropriate to the new gender role. Our study did not ask explicitly about body size or shape, but several participants commented on the significance of "feminine characteristics", the need to "pass" as a "natural member of the female sex", and of their wish to have surgery before "masculine characteristics develop": [I made the n'ght decision to have surgery, hutl I must note that this kind of thing depends very much on appearance particularly ifone is tall and has large hands. I was lucky enough to have money to pay for extensive facial alterations, which reduced the masculinity ofa uery masculineface In practice this tends to he more important than [;races. I know transsexuals who are quite pretty, and for them EVERYTHING else isfor[;iven. A vagina helps one to feel much more complete, hut without passin[; it would mean little in our higoted society (If) 11).
Conclusion This survey of 57 patients attending a clinic in Sydney reveals a high level of satisfaction with both surgical outcome and the social and psychological impact of surgery. This same result occurred across a number of areas, including those of friendships and social life. The qualitative data suggests an explanation for this consistency of responses to questions about surgery, increases in life satisfaction, and improvements in participants' social lives and friendships. It appears that undergoing sex re-assignment surgery provides a much needed increase in self-esteem and selfconfidence, as genital changes are generally only known to the participant, the surgeon, and perhaps a close friend or sexual partner.
Although this study has not involved a large group of patients in the statistical sense, it is a large study when compared to those reported in the literature. Many of these studies contain fewer than 57 participants; for example, Perkins (994) reports on a group of 38, Walters et al. 0986:147) on 22, Hunt and Hampson (980) on 17, Lindemalm et al. (986) on 13, Bodlund and Kullgren (996) on 19, and Blanchard et al. (983) on 55. This study challenges some of the findings established by previous studies. For example, our study suggests that contrary to the findings of Lundstrom et al. (984), Murray (in Lowe 1996:52), and Lindemalm et al. (987), successful social, psychological and clinical outcomes can be achieved even where patients are well over the age of 30 at the time of surgery. Moreover, our findings offer evidence to suggest that a good surgical outcome, while important, is not fundamental to overall satisfaction. This challenges the findings of studies such as Eldh et al. (997) which conclude that optimal surgical results are essential for an overall successful outcome, and it supports other studies (Lindemaim et al., 1987; Lundstrom et al., 1984) which have concluded that a good surgical result is important but not essential to overall success. Our study indicated that a successful surgical outcome (in regard to both function and appearance) is one of several factors that contribute to patient satisfaction. Other factors include friendship networks, employment status, personal resources and expectations, and prevailing social attitudes. Most importantly, in conclusion, this study offers strong evidence to support the findings of other studies (such as Eldh et al., 1997; Walters et al., 1986; Blanchard, Clemmernsent & Steiner, 1983; and Hunt & Hampson, 1980) that surgical sex re-assignment can have a positive social and psychological impact on the lives of patients.
Acknowledgments The authors wish to thank all those involved in this research. We are grateful to Dr Peter Haertsch, Plastic Surgeon, Epping NSW, who provided confidential access to patients, and assistance with planning and administrative resources; his staff, particularly Cheryl Hayward for her tireless and invaluable contribution to data collection; and special thanks to all the patients who have undergone this procedure and were willing to share their experiences with us.
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Fran Collyer Department of Sociology and Social Policy H03 Institute Building University of Sydney Sydney, NSW, 2006
Catherine Heal C/- PO Box 441 Epping NSW 2121 AUSTRALIA
AUSTRALIA
Email:
[email protected]
Australian Journal of Primary Health -
Vol. 8, No.3, 2002
Correspondence to Fran Collyer
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