Archives o f Sexual Behavior, Vol. 10, No. 2, 1981

A Study of Pre- and Postsurgical Transsexuals: MMPI Characteristics

Michael Fleming, Ed.D.,' Deborah Cohen, ~ Patricia Salt,' David Jones,' and Sharon Jenkins'

This study examines assessment issues concerning transsexualism through the use o f the Minnesota Multiphasic Personality Inventory (MMPI). The M M P I was administered to 20 transsexuals matched within sex on age and education: five presurgical male-to-females, five postsurgical male-to- females, five presurgical female-to-males, and five postsurgical female-to- males. Mean T scores for each o f these four subsamples were examined in comparison to normative groups. Comparisons among the four subsamples showed significant differences in mean raw scores attributable to both sex and surgical status. The most striking o f these comparisons indicated that postsurgical subjects had a higher level o f psychological adjustment.

KEY WORDS: transsexual; MMPI; sexual identity.

The phenomenon of transsexualism continues to be questioned from a number of different perspectives, with such isues as diagnosis, assessment, and treatment receiving considerable attention in the psychiatric literature. The present study attempts to look at assessment concerns through the use of the Minnesota Multiphasic Personality Inventory (MMPI) with both pre-: and postsurgical transsexuals. The MMPI is of particular relevance because of the central place it has come to have in psychological test batteries, as well as its appearance in literature on transsexualism.

Within the past 5 years a small number of studies have examined the MMPI scores of transsexual men and women seeking sex-reassignment

'Boston University, Boston, Massachusetts.

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0004-0002/81/0400-0161503.00/0 © 1981 Plenum Publishing Corporation

162 Fleming, Cohen, Salt, Jones, and Jenkins

surgery. In 1974, Rosen administered the MMPI to 34 people with gender- related problems, eight of whom were genetic males seeking sex-reassign- ment surgery and an unspecified number of whom were genetic females seeking sex-reassignment surgery. These transsexual subjects scored highest above the mean on both the Masculinity-Femininity (Mf) and Psychopathic Deviate (Pd) scales. In addition, while the male-to-females obtained minor peaks on Schizophrenia (Sc) and Hypomania (Ma), the female-to-males ob- tained minor peaks on Depression (D) and only tertiary peaks on Sc. Rosen concludes that the profiles obtained by his sample are indicative of "indi- viduals with difficulties in social adjustment and in making social contact."

In a more recent study which compared the raw MMPI scores of pre- surgical female-to-males with those of women seeking jejunoileal bypass surgery for obesity and women seeking psychiatric outpatient treatment, Roback et al. (1976) report findings similar to those of Rosen. This trans- sexual subsample scored above the mean ("beyond a T-score equivalent of 65") on both Mf and Pd. However, with the exception of the Mf scale, the mean raw scores of the female-to-males were not significantly more deviant than those of the other two subsamples. Roback et al. conclude that women seeking sex-reassignment surgery are neither severely neurotic nor psychotic, and note that the high Mf and Pd scores obtained by their female-to-male subjects are comparable to the scores which "are often obtained by women who experience social difficulties related to their behavioral deviation from sex-role conventions."

Finney et al. (1975) administered the MMPI to 19 males and one female seeking sex-reassignment surgery, and performed a computerized analysis of the scores to form profiles. In addition to noting elevations above the mean on both Mf and Pd, Finney et al. also report that a majority of the subjects received either a primary (N = 3) or secondary ( N = 10) diagnosis of hysterical personality. They further note that only a minority of the subjects presented with schizoid or paranoid features or both and conclude on the basis of their sample that transsexuals fall somewhere between the psychiatrically ill and healthy.

In summation, it should be noted that all three of the above-men- tioned studies employed subjects who were seeking sex-reassignment surgery. The only consistent finding among these three studies was that all of the subjects obtained elevations above the mean on both the Masculine- Feminine and the Psychopathic Deviate scale. In addition, two of the studies (Rosen, 1974; Finney et al., 1975) noted elevations on Hypomania and Schizophrenia. Finney et al . 's findings that most of their transsexual subjects received either primary or secondary diagnoses of hysterical per- sonality were not supported by the findings of either Rosen (1974) or Roback et al. (1976).

Transsexuals and MMPI 163

The present study examines the MMPI scores of both presurgical and postsurgical transsexual men and women as part of an ongoing research project concerned with the assessment of sex-reassignment surgery. T h e term "presurgical" is used here to describe those men and women who have not yet had surgery, but continue to move toward the completion of sexual reassignment. This distinction is made in light of the recent publication by Meyer and Reter (1979), in which it is suggested that there exists a group of "nonsurgical" transsexuals who "self-select" against surgery by never successfully completing a designated trial period. It is our belief that the subjects in this study who have not yet had surgery are, in fact, "pre- surgical"; they all either have completed the trial period, or continue to work actively toward its completion and the completion of sexual reassign- ment. The purpose of this paper is two-fold: (1) to compare the scores of this presurgical sample with those previously reported by others, and (2) to give some much-needed attention to the postsurgical transsexual and how (s)he might differ from the transsexual who has not yet had surgery.

The most obvious problem inherent in employing the MMPI with a transsexual population is that of using the established T-score norms, which differ for males and females. When one is working with a group of people who believe themselves to be the opposite of their biological sex, it becomes problematic which T score to use. Although T scores do not always differ considerably between males and females, Holmes (1967) has pointed out that T scores are adjusted in order to account for what is believed to be a higher level of symptom admission in women.

A case can certainly be made for the use of T scores of the desired sex rather than the biological sex when working with a transsexual population. Since the chief complaint of male-to-females is that they are not "normal males," perhaps their scores should not be compared to those of "normal males"; the same, of course, would be true for female-to-male transsexuals. Reports in the literature on the use of the MMPI with transsexual popula- tions neither address this discrepancy nor make adjustments for it.

As a partial solution to this problem, the present study cites raw scores--which do not differ for males and females--as well as T scores calculated by biological sex. T Scores are presented in order to assist in the comparison of the present findings with those of other studies citing T scores. In addition, T-score conversions for both the desired and biological sex are presented for the Hysteria scores of our male-to-females. The present study also reports raw Mf scores by both biological and desired sex, and calculates the corresponding T scores for both the biological and desired sex. In future studies with transsexual populations it might be best to either calculate T scores by both biological and desired sex, or to devise norms based on a transsexual sample.

164 Fleming, Cohen, Salt, Jones, and Jenkins

M E T H O D

Subjects and Procedure

In the winter of 1978 and spring of 1979, 20 transsexual clients of the Boston Gender Identity Service were individually administered the MMPI. This sample of 20 subjects comprised four subsamples: (1) five presurgical male-to-females; (2) five postsurgical male-to-females; (3) five presurgical female-to-males; and (4) five postsurgical female-to-males.

Prior to surgery, all of the postsurgical subjects had successfully completed a 1-year trial period, which consisted of living the role of the desired sex in both personal and vocational life, and taking hormones. Four of the presurgical female-to-males have completed this trial period; none of the presurgical males has done so to date. At the present time, all of the pre- surgical subjects are active clients in the gender service.

The two male-to-female subsamples were matched for age, years of education, and number of months in the gender service; the two female-to- male subsamples were also matched on these variables. The male-to-females had a mean age fo 35.9 years, a mean of 15.3 years of education, and a mean of 37 months in the gender service. The female-to-males had a mean age of 27.9 years, a mean of 13.4 years of education, and a mean of 34.9 months in the gender service. Although the subjects were not matched across biological sex, the only significant difference between the biological males and females was on education. The biological males had significantly more years of education than the biological females.

Analysis o f Data

A series of two-way analyses of variance was performed on the raw MMPI clinical scale scores in order to evaluate the effects of both biological sex and surgical status. A similar series of two-way analyses of variance was also performed on raw scores derived from the nine MMPI critical item categories: (1) Distress and Depression; (2) Suicidal Thoughts; (3) Ideas of Reference, Persecution, and Delusions; (4) Peculiar Experiences and Hallucinations; (5) Sexual Difficulties; (6) Authority Problems; (7) Alcohol and Drugs; (8) Family Discord; and (9) Somatic Concerns.

In addition, T scores on the MMPI clinical scales were computed by biological sex for each subject and mean T scores were calculated for each of the four subsamples. This was done to aid in the comparison of the present findings with those of other studies reporting Tscores.

Transsexuals and MMPI 165

RESULTS

Table I presents the mean raw scores and standard deviations for each of the four subsamples; the T-score equivalents are presented in Table II. The presurgical males obtained mean elevations above T = 80 on Mf as male (T = 88) and above T = 70 on both Pd and Sc (T = 75 and T = 73, respectively). This subsample also obtained minor peaks on Ma, Pt, Hy as male, and D, with T scores between 66 and 67. On Hy as female, the pre- surgical males obtained a mean score of T -- 61. The presurgical females obtained mean elevations above T = 70 on Mf as male (T = 76); Ma, Pa, and Pd were between 60 and 70.

The postsurgical male-to-females presented profiles with mean eleva- tions above T = 80 on Mf as male, and above T = 60 on Pd; both the K

Table I. Mean Raw Scores and Standard Deviations for the Four Groups a

Presurgical Postsurgical Presurgical Postsurgical MMPI scale females females males males

Lie 4.6 5.2 4.0 6.6 (1.7) (1.5) (2.2) (3.6)

Validity 5.2 3.6 7.4 3.0 (3.9) (2.1) (5.0) (2.0)

Test-Taking 13.0 14.0 18.0 17.4 Attitude (4.5) (7.4) (3.8) (5.1)

Hypochondriasis 13.8 12.6 13.8 10.4 (3.2) (5.5) (3.3) (2.1)

Depression 17.8 18.4 23.4 18.8 (4.4) (0.5) (9.8) (5.1)

Hysteria 21.8 22.6 25.4 22.0 (5.1) (4.7) (5.2) (3.0)

Psychopathic 23.4 23.4 29.6 25.4 Deviate

Masculinity and Femininity/Male

Masculinity and Femininity/Female

Paranoia

Psychasthenia

Schizophrenia

Hypomania

Social

33.8 31.4 39.8 36.6 (2.2) (5.5) (6.8) (6.0) 35.0 32.8 41.0 38.8 (2.6) (3.0) (4.7) (4.8) 12.2 9.4 9.8 10.4 (3.8) (1.5) (3.7) (4.4) 24.2 25.6 31.2 24.6 (4.3) (3.4) (8.0) (3.1) 28.4 24.8 34.0 26.0 (8.0) (7.6) (8.5) (4.5) 24.8 19.4 23.8 20.4 (4.6) (4.3) (3.8) (2.4) 23.8 27.6 23.8 23.4 (9.7) (8.6) (6.3) (6.6)

aThe standard deviation is given in parentheses below the mean for each group.

166 Fleming, Cohen, Salt, Jones, and Jenkins

Table II. Mean TScores for Each of the Four Groups (Based on Biological Sex)

Presurgical Postsurgical Presurgical Postsurgical MMPI females females males males

Lie 51 54 49 58 Validity 56 51 60 51 Test-Taking Attitude 52 53 60 61 Hypochondriasis 52 48 56 48 Depression 47 48 66 55 Hysteria 56 57 66 60 Psychopathic Deviate 61 61 75 65 Masculinity/Femi-

ninity/Male 76 72 88 81 Masculinity/Femi-

ininity/Female 49 58 41 47 Paranoia 63 54 55 57 Psychasthenia 48 51 67 53

Schizophrenia 59 53 73 57 Hypomania 70 56 67 59 Social 52 53 49 49

scale and the H y as male scale were e levated to 60. Their mean H y as female score was T = 58. The pos t surg ica l f emale - to -ma les presented prof i les with a mean e levat ion above T = 70 on M f as male , and a m i n o r peak on Pd .

The impor t ance o f the m e t h o d o l o g i c a l issue to n o r m reference for the M f scale is i l lus t ra ted by the d i f fe ren t results tha t are ob ta ined when M f scores for bo th b io logica l sex and des i red sex are cons idered . Both the pre- surgical and pos tsurg ica l males scored well above the mean on M f as male , bu t well wi th in the n o r m a l range on M f as female . The pre- and pos t surg ica l females , on the o ther hand , scored wi th in the n o r m a l range on M f as female and well above the n o r m a l range on M f as male .

The Hys te r i a scale scores o f the b io logica l males in this s tudy, which are p resen ted by bo th b io logica l and des i red sex, also deserve some a t ten- t ion. Whi le bo th the pre- and pos t surg ica l males ob t a ined a score o f T = 60 or g rea te r on H y as male , this was no t the case on H y as female . W h e n the H y scores were c o m p a r e d to those o f n o r m a l females , the presurgica l males ob t a ined a mean score o f T = 61 and the pos t surg ica l males ob t a ined a mean score o f T = 58.

The two-way analyses o f var iance revealed a n u m b e r o f d i f ferences a m o n g the popu la t i ons . The presurg ica l subjects scored s ignif icant ly higher than the pos t surg ica l subjects on the M a scale ( p < 0.022), while the Sc scale ( p < 0.096) a p p r o a c h e d s ignif icance. The only cl inical scale which served to d i f fe ren t ia te the sample by b io logica l sex was the M f scale, on which the b io logica l males scored s igni f icant ly more " f e m i n i n e " than the b io log ica l females (Mf as male , p < 0.035; M f as female , p < 0.004).

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Of the nine critical item categories, four served to differentiate the sample either by biological sex, surgical status, or a two-way interaction of biological sex and surgical status. The difference in Suicidal Thoughts scores proved significant for both main effects and the interaction (p < 0.053) because the presurgical males were the only subsample to obtain a score greater than zero.

The difference in Somatic Concerns approached significance by surgical status with the presurgical subjects reporting more somatic con- cerns than the postsurgical subjects (p < 0.063) and reached significance by biological sex with females reporting more somatic concerns than males (p < 0.023). The Sexual Difficulties category yielded a significant difference by biological sex, with males reporting a greater number of sexual diffi- culties than females (p < 0.025). The final category, Ideas of Reference, Persecution, and Delusions, proved to differentiate the sample by a two- way interaction (p < 0.039); only the presurgical females obtained scores greater than 1.

DISCUSSION

Individual Subsamples

An examination of the mean T scores for each of the four subsamples reveals that the presurgical male-to-females, who obtained the greatest number of scales elevated above T = 60, are the subjects who are most at risk. Although they report a large number of "feminine" interests and may at times present as females, the presurgical male-to-females in this study have yet to adopt the female role in all aspects of their lives. The fact that none of them have successfully completed the trial period of cross-living and taking hormones can be seen as a behavioral measure which, corre- sponding to their MMPI scores, indicates their greater level of anxiety and difficulty around issues of their transsexualism.

On the basis of T-score evaluations, the subsample of presurgical female-to-males appears to be the next group at risk. Although their mean Pd elevation (T = 61) was not as high as that obtained by the presurgical female-to-males in Roback et al's (1976) study, the fact that it exceeded T = 60 suggests that our presurgical females may experience some social diffi- culties due to their deviation from conventional sex roles. One might argue that their successful completion of the trial period accounts for their lower elevation on Pd than the presurgical males in this study. Since they are now living as males in both their personal and vocational lives, the social stigma they experience is presumably less than that of the presurgical males.

168 Fleming, Cohen, Salt, Jones, and Jenkins

The overall picture of the presurgical female-to-males, on the basis of their mean Tscores, tends to concur with our general impressions of women who come to the Gender Identity Service seeking sex-reassignment surgery. Such women do not tend to deny actively any " feminine" aspects of their personality, and this is evidenced by their elevation above the mean on Mf as male. This finding that the presurgical female-to-males score somewhere between the dimensions of masculinity and femininity is in accordance with the findings of Fleming et al. (1980), that female-to-male transsexuals tend to score within the androgynous range on the Bem Sex-Role Inventory. In addition, Gender Identity Service therapists have noted that presurgical female-to-males adopt a rather active and competitive approach to their personal and vocational lives, which may correspond to their elevation on the Hypomania scale.

On the basis of T scores, the postsurgical female-to-male appear to have the fewest problems in adjustment. Their elevation on Mf as male (T = 72) clearly indicates that they make no effort to deny any " feminine" interests. Furthermore, their mean Tscore on Mf as female (T = 58) is ob- tained by many " n o r m a l " women who express some interest in "mascu- l ine" activities. As is the case for the presurgical females, the postsurgical female-to-males seem to be more androgynous than stereotypically "mascul ine" or " feminine ."

Comparisons Between Subsamples

The results of the analyses of variance performed on the raw scores across both biological sex and surgical status raise a number of important issues. Initially, one is struck by the fact that the presurgical subjects scored significantly higher than the postsurgical subjects on one clinical scale (Ma), and showed a tendency to score higher on two others (F and Sc). In addi- tion, in three of the critical item categories (Somatic Concerns; Suicidal Thoughts; Ideas of Reference, Persecution, and Delusions) one or both of the presurgical subsamples scored significantly higher than the postsurgicat subjects. It is tempting to conclude that surgery has a beneficial effect for transsexuals. However, these findings must be interpreted with caution because this study did not involve the follow-up of one group of trans- sexuals from pre- to postsurgery. On the other hand, these results would seem to contradict the recent report which minimized the effects of reassign- ment surgery (Meyer and Reter, 1979). In light of the implications of that report, the present findings seem sufficient to warrant further and more thorough attention to the effects of sex-reassignment surgery.

If having had surgery did not create the differences between the two groups, another possibility is that those subjects who were tested post-

Transsexuals and MMPI 169

surgically would have scored within the same ranges had they been tested presurgically. This implies the possibility of distinguishing those people who are prepared to make or who have already made the necessary adjustments to the successful completion of sex-reassignment surgery from those who may need additional time and /o r counsel.

CONCLUSION

In closing it is important to note that the present study revealed results similar to those of Rosen (1974), Roback et al. (1976), and Finney et al.

(1975), in that all of the subjects obtained elevations of T = 60 or higher on Pd. In addition, our results support the previous findings (Rosen, 1974; Finney et al . , 1975) that male-to-females score above the mean on Mf as male, but do not support the findings that female-to-males score above the mean on Mf as female (Roback et al . , 1976).

Without a complete profile analysis of the MMPI scores it is impossible to make any diagnoses or discuss the personality dynamics that may be common to each of our four subsamples. All one can say is that the presurgical subjects, especially the presurgical males, obtained the greatest number of elevated scales and as such are most at risk. On the basis of our present findings we cannot form an opinion as to the degree of difficulty the presurgical subjects experience, although it is clear that it is greater than that experienced by the postsurgical subjects. Whether the completion of surgery is responsible for the postsurgical subjects' increased adjustment, or whether this group was at the same higher level of adjustment prior to surgery, cannot be discerned due to the nature of this study. Only future research with the MMPI and transsexual populations can answer this. Such research should be aimed at both evaluating reassignment surgery and evaluating presurgical screening through the use of the MMPI.

ACKNOWLEDGMENT

This paper would not have been possible without the help of Joanie Spitz.

REFERENCES

Finney, J. C., Brandsma, J. M., Tondow, M., and Lemaistre, G., (1975). A study of trans- sexuals seeking gender reassignment. Am. J. Psychiatr. 132: 962-964.

170 Fleming, Cohen, SaJt, Jones, and Jenkins

Fleming, M., Jenkins, S., and Bugarin, C. (1980). Questioning current definitions of gender identity: Implications of the BEM Sex-Role Inventory for transsexuals. Arch. Sex. Behav. 9: 13-26.

Holmes, D. S. (1967). Male-female differences in MMPI ego strengths: An artifact. J. Consult. Psychol. 31 : 408-410.

Meyer, J. K., and Reter, D. J. (1979). Sex reassignment. Arch. Gen. Psychiatr. 36: 1010-1015.

Roback, N. B., McKee, E., Webb, W., Abramowitz, C. V., and Abramowitz, S. I. (1976). Psychopathology in female sex-change applicants and two help-seeking controls. J. Abnorm. Psychol. 85: 430-432.

Rosen, A. C. (1974). Brief report of MMPI characteristics of sexual deviation. PsychoL Rep. 35: 73-74.