A Critique of Paul McHugh’s ‘Surgical Sex’

A Critique of Paul McHugh’s ‘Surgical Sex’

 by Anna Magdalena

This article provides an in-depth examination, section by section, of Paul McHugh’s extremely damaging article published in First Things Magazine.

As a Catholic who is intellectually engaged on transgender issues, I’ve encountered a whole lot of bullshit from various corners of conservative psychology and ethics. What I’ve found is that about 90% of the crap I deal with can be traced back to one source: the infamous Dr. Paul McHugh.

Paul McHugh was the psychiatrist-in-chief at Johns Hopkins Hospital from 1975 to 2001, and is known for shutting down Johns Hopkins’ gender program because of his own dissatisfaction with the sex reassignment surgery process.

Just about every anti-transgender writer out there pulls heavily from McHugh’s understanding of the issue. Several older Catholics I’ve spoken to have pulled me aside and said in the most knowing tone: “You know they stopped doing surgeries at Johns Hopkins.” As if that says it all.

My least favorite Catholic writer, the now AWOL Dr. Richard Fitzgibbons, pulls almost exclusively from McHugh, who has been called to various Church meetings and conferences to advise clergy on the issue. Unfortunately for everyone, this man who counsels the entire conservative world on trans issues doesn’t even have his terminology straight.

The article opens with this very telling line:

 Where did they get the idea that our sexual identity (“gender” was the term they preferred) as men or women was in the category of things that could be changed?

 Here in the opening sentence, McHugh already demonstrates his utter inability to grasp the issue. For one thing, he confuses the terms ‘sex’ and ‘gender’ when the whole point of using the term ‘gender’ is to denote an inner identity separate from chromosomal sex. He assumes that transsexuals seek to change their gender (or sex – apparently the two are the same thing), instead of conform their body to their mind or soul.

The problem is that McHugh’s exposure to gender affirmation surgery (then called sex reassignment surgery) was largely in the 90s, when language and discussions about these issues were hardly nuanced. Back then, it was more common to use ‘sex change’ rhetoric, as if one could be reborn as a completely different sex. For many transsexuals, it is understood that we are born with a chromosomal sex, which will never change, but we are also born with an inner gender identity, which will also never change. Gender affirmation surgery doesn’t seek to magically change a person’s chromosomal structure; it seeks to align a person’s bodily structure with their neurological reality.

Men (and until recently they were all men) with whom I spoke before their surgery would tell me that their bodies and sexual identities were at variance. Those I met after surgery would tell me that the surgery and hormone treatments that had made them “women” had also made them happy and contented.

Maybe transwomen in the 90s would have said “the surgery makes me a woman,” but I know many transsexuals today (and then) would say “I’m already a woman, but the surgery will allow me to live more fully in my female identity.”

It’s worth noting that here and elsewhere McHugh admits transsexuals are generally satisfied with the surgery.

None of these encounters were persuasive, however. The post-surgical subjects struck me as caricatures of women. They wore high heels, copious makeup, and flamboyant clothing; they spoke about how they found themselves able to give vent to their natural inclinations for peace, domesticity, and gentleness — but their large hands, prominent Adam’s apples, and thick facial features were incongruous (and would become more so as they aged). Women psychiatrists whom I sent to talk with them would intuitively see through the disguise and the exaggerated postures. “Gals know gals,” one said to me, “and that’s a guy.”

This passage is incredible. It completely fails to take into account the lifetime of social trauma and hormonal dissonance these transwomen face.

For one, the late-onset transsexuals McHugh dealt with passed through 30-60+ years of extreme social trauma striving to live in their expected masculine roles. If you expect someone who has spent a lifetime striving to act in a macho role to suddenly re-integrate and perfectly express their inner femininity, you’re crazy.

They wore high heels,

How dare they!

copious makeup

Well, unfortunately the effects of forty years of testosterone on a transwoman generally rob her of the same physical femininity many cisgender women take for granted, so makeup is less optional. Also, these poor girls never had the same makeup tutorials from their mother as many cisgender women. Moderation is a skill learned with time. How many teenage girls wear too much eyeliner at first?

and flamboyant clothing.

These women have passed through decades of repression of their femininity. If they are a little cavalier about it and don’t have the same restraint that cisgender women learn from decades of experience, I think they can be forgiven.

— but their large hands, prominent Adam’s apples, and thick facial features were incongruous

How superficial can you be!? McHugh admits these women are satisfied with the surgery, but then makes a psychological evaluation of them based on their physical appearance!? It’s bad enough these poor folk’s bodies suffer decades of testosterone, but McHugh comes along and adds insult to their injury, and then classifies them as psychopaths for their trouble.

Women psychiatrists whom I sent to talk with them would intuitively see through the disguise and the exaggerated postures.

Again, since McHugh is largely working with very late-transitioning transsexuals in the 90s, the ability of these women to pass in society and re-integrate their lives is often diminished. I once showed a female friend of mine videos of MtF transsexuals more from my generation (so earlier and more recent transitions). After both videos (here and here) she concluded: “Oh my gosh, she’s definitely a woman!” (Read this post about the myth that transwomen are “spottable”).

Once again, McHugh uses the most superficial physical criteria for evaluating the psychological welfare of these transsexuals. He replaces psychology with misogyny and homophobia.

The subjects before the surgery struck me as even more strange, as they struggled to convince anyone who might influence the decision for their surgery. First, they spent an unusual amount of time thinking and talking about sex and their sexual experiences; their sexual hungers and adventures seemed to preoccupy them.

I don’t know if McHugh’s observations are accurate, but I do know that many transsexuals are asexual. I know that I myself am not particularly preoccupied with sex. Maybe the reason these particular transsexuals are talking so much about sex is they think it will help them secure an SRS, or maybe because there is an obvious functional relationship between sex as a woman and having a vagina. At the very least it’s obvious these transsexuals wouldn’t have to overstate their case for a surgery if McHugh wasn’t so against it in the first place.

Second, discussion of babies or children provoked little interest from them; indeed, they seemed indifferent to children.

I don’t know if McHugh’s particular subjects happened to be indifferent to babies, but I know for myself that I’m generally more interested in babies than in sexual intercourse. Of course I want intimacy like any other person, but raw sexual intercourse doesn’t seem as sublime to me as the mystery of motherhood. Maybe that’s just me, but there seems a lot wrong in McHugh’s implicit assumption that transwomen generally have a “male-typical” love for sex as opposed to a “female-typical” love for babies.

Also, there is the brute fact that since we MtF trans are born without uteruses, normal biological motherhood is out of the question. The fact that I personally am preoccupied with motherhood is painful for me since it’s an unfulfillable desire, and I wouldn’t blame other transgirls for bracketing the issue.

But third, and most remarkable, many of these men-who-claimed-to-be-women reported that they found women sexually attractive and that they saw themselves as “lesbians.”

Sexuality is complicated for trans people and it seems like there might be a rough correlation between how long a transsexual stays in the closet and where they end up on the sexual spectrum. I also know that for many “lesbian” transsexuals, their attraction to women is hardly that of a straight cisgender guy. To quote psychologist Anne Vitale on the subject:

[Cloistered male-to-female transsexuals] appear to others and even to themselves to be heterosexual. Although as a group they are not especially active daters, they clearly prefer to date girls when they do date. Significantly, unlike other boys, their dating motives are markedly different. For these boys, being on a date with a girl is a chance to spend time with a girl in a way not generally allowed under other circumstances. Dating serves two purposes for these boys. The first is social, as it gives them the all-important appearance of being normal. The second is therapeutic. Being close to a girl’s softness, and even her female smell, has a mitigating effect on gender expression deprivation anxiety.

the opinion in psychiatric circles that one’s “sex” and one’s “gender” were distinct matters, sex being genetically and hormonally determined from conception, while gender was culturally shaped by the actions of family and others during childhood.

McHugh is assuming that transsexuality is about a “culturally shaped” gender identity, while current biological research suggests that gender identity is actually physiologically encoded. He is fighting a straw man: he is uncomfortable with the ideas that ‘gender doesn’t matter’ and ‘people are what they choose to be,’ so he invalidates the entire transgender condition, when in actuality transgenderism seems to prove that at least some aspect of gender identity is encoded.

This is all extremely ironic, since many people who cite McHugh as their main source then try to provide ‘socialization’ theories for gender dysphoria such as problems with how the gender dysphoric person was raised.

[Jon Meyer (McHugh’s protégé)] found that most of the patients he tracked down some years after their surgery were contented with what they had done and that only a few regretted it. But in every other respect, they were little changed in their psychological condition. They had much the same problems with relationships, work, and emotions as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled.

So let me get this straight: McHugh is labeling these transsexuals as psychologically disturbed because after a lifetime of depression, anxiety, and social discomfort, they aren’t magically transformed into perfect social butterflies overnight? Give me a break!

Well, obviously surgery isn’t a magic wand or fairy dust that will miraculously fix everything in an instant. I can see why some transwomen, after years of pain, might hold out hope that the surgery will end their journey completely. However, full emotional and spiritual integration is a lifelong journey that requires more than favorable external (bodily) conditions.

We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation so they enjoyed cross-living after it.

This is begging the question. He saw the results as confirming his own presumptions, which are that these are delusional men seeking a fetish fulfillment. He interpreted what he saw in these transsexuals according to his assumption that “these are kinky men” to conclude that “these are kinky men.” A, B, therefore A is not a good argument, especially when premise A is false.

We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.

And how has that gone? Have you had any success rewriting trans peoples’ personalities? Have you exorcised their souls? How has that worked out, Dr. McHugh?

Most of the cases fell into one of two quite different groups. One group consisted of conflicted and guilt-ridden homosexual men who saw a sex-change as a way to resolve their conflicts over homosexuality by allowing them to behave sexually as females with men. The other group, mostly older men, consisted of heterosexual (and some bisexual) males who found intense sexual arousal in cross-dressing as females. As they had grown older, they had become eager to add more verisimilitude to their costumes and either sought or had suggested to them a surgical transformation that would include breast implants, penile amputation, and pelvic reconstruction to resemble a woman.

These ideas are ripped straight from the pseudoscientific theories of Ray Blanchard and Anne Lawrence. This is called ‘the sexual theory of transsexuality,’ and it is largely rejected by the psychological community.

This theory comes from an instinct among some conservative thinkers to (a) sexualize the problem and assume it’s all about intercourse, and (b) collapse transsexuality and homosexuality into one idea. All I can say is this demonstrates a very basic confusion about the difference between gender identity and sexual orientation.

Also, from my own personal experience I cannot help but think the division of transgender people into these two distinct groups is bullshit. The problem is that trans people like me fall somewhere in between. Group 1 transitions in their teens, group 2 when middle aged, and people like me transition in their twenties. Group 1 likes men, group 2 likes women, and people like me often like both or switch. Group 1 passes very well, group 2 passes less easily, and people like me pass fairly well.

What this looks like to me is a spectrum. If a person comes to terms with their transgenderism earlier on, they integrate and pass more easily and their sexuality usually develops in a more ‘straight female’ direction. The later a person comes to terms with their transgenderism, the less easy it is to integrate and pass and the more masculine their sexuality develops.

Also, it is ridiculous to think the desire for surgery is primarily sexually driven because the gender reassignment process complicates sex rather than permits it. For one thing, being transgender makes finding a life partner that much harder. Secondly, do I even have to point out that removing one’s testicals both diminishes libido and makes either kind of sex drive that supposedly causes the whole thing – gay sex or autogynephilic masturbation – quite literally impossible!?

McHugh then begins the second part of his paper, which talks about the now largely discontinued practice of genital surgery on children born with ambiguous genitalia.

Several conditions, fortunately rare, can lead to the misconstruction of the genito-urinary tract during embryonic life. When such a condition occurs in a male, the easiest form of plastic surgery by far… is to remove all the male parts, including the testes, and to construct from the tissues available a labial and vaginal configuration. […] This practice had become almost universal by the mid-1970s. […]

Reiner, however, discovered that such re-engineered males were almost never comfortable as females once they became aware of themselves and the world. From the start of their active play life, they behaved spontaneously like boys and were obviously different from their sisters and other girls, enjoying rough-and-tumble games but not dolls and “playing house.” Later on, most of those individuals who learned that they were actually genetic males wished to reconstitute their lives as males (some even asked for surgical reconstruction and male hormone replacement) — and all this despite the earnest efforts by their parents to treat them as girls.

McHugh uses this as evidence against transsexuality, but I think it provides evidence for transsexuality. The point is that each person has an inbuilt gender identity, which no amount of socialization can change. For these cisgender boys who were raised as girls, nothing could change their gender identity to female. For a transgender girl who is raised as a boy, nothing can change their gender identity to male.

SIDE NOTE: Physical intersex conditions are actually much more common than previously thought. The current estimate of people receiving corrective surgery for a genital abnormality, according to the Intersex Society of North America, is 1-2/1000, which is roughly as common as Down Syndrome.

Having looked at the Reiner and Meyer studies, we in the Johns Hopkins Psychiatry Department eventually concluded that human sexual identity is mostly built into our constitution by the genes we inherit and the embryogenesis we undergo. Male hormones sexualize the brain and the mind.

And what if the brain gets female hormones instead of male hormones, as many are now suggesting happens for a transgender person?

Sexual dysphoria — a sense of disquiet in one’s sexual role — naturally occurs amongst those rare males who are raised as females in an effort to correct an infantile genital structural problem. A seemingly similar disquiet can be socially induced in apparently constitutionally normal males, in association with (and presumably prompted by) serious behavioral aberrations, amongst which are conflicted homosexual orientations and the remarkable male deviation now called autogynephilia.

So he’s saying that nothing can change a cisgender male’s gender identity, even if that cisgender male has a vagina and is raised as a girl! However, transgender males are different and can have their gender identity “socially induced” into a state of confusion. This makes no sense!

For children with birth defects the most rational approach at this moment is to correct promptly any of the major urological defects they face, but to postpone any decision about sexual identity until much later, while raising the child according to its genetic sex. Medical caretakers and parents can strive to make the child aware that aspects of sexual identity will emerge as he or she grows. Settling on what to do about it should await maturation and the child’s appreciation of his or her own identity. […] Then as the young person gains a sense of responsibility for the result, he or she can be helped through any surgical constructions that are desired. Genuine informed consent derives only from the person who is going to live with the outcome and cannot rest upon the decisions of others who believe they “know best.”

This pretty much lines up with a transgender philosophy of identity, in which a person often needs to mature before their latent gender identity becomes clear.

The “transgender” activists (now often allied with gay liberation movements) still argue that their members are entitled to whatever surgery they want,

Whatever happened to the earlier quote: “as the young person gains a sense of responsibility for the result, he or she can be helped through any surgical constructions that are desired”?

and they still claim that their sexual dysphoria represents a true conception of their sexual identity.

So trans people claim our gender identity is in fact our gender identity. This is being held as incorrect against what? Against McHugh’s personal conflation of gender identity with chromosomal sex?

They have made some protests against the diagnosis of autogynephilia as a mechanism to generate demands for sex-change operations, but they have offered little evidence to refute the diagnosis.

Autogynephilia is a documented phenomenon among some transgender people, but McHugh assumes it is the cause of gender dysphoria when it is likely an effect of gender repression. The thing is that most of the psychological community has rejected the autogynephilic/sexual theory of transgenderism. One of the problems with the theory is it doesn’t have any evidence! It’s a dogmatic theory that ignores the majority of the transgender experience for the sake of providing a neat sexualized explanation.

One might expect that those who claim that sexual identity has no biological or physical basis would bring forth more evidence to persuade others. But as I’ve learned, there is a deep prejudice in favor of the idea that nature is totally malleable.

Never mind that the trans movement and current psychology are actually working in the opposite direction to show that sexual identity does have a biological basis. Once again, McHugh’s stance is outdated and irrelevant.

McHugh demonstrates fallacious patterns of arguing that recur in the vast majority of other anti-trans “psychology” out there. Here and elsewhere the writers rely on (a) attacking a straw man (b) ad hominem (personal and superficial) attacks against trans people’s integrity and sanity, (c) double standards, like McHugh’s inconstancy about whether gender identity can change, and (d) non-falsifiable ideas and non-testable theories.

It’s unbelievable to me that this article is essentially the basis for all anti-trans rhetoric out there. I don’t want to sound mean, but McHugh really sounds like an old fogey. His ideological dissent and personal observations about transsexuality produce a mess of contradictory, inconsistent, fallacious arguments.

I really hope the world gets over this man’s small thinking.


39 thoughts on “A Critique of Paul McHugh’s ‘Surgical Sex’

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  11. This is a truly excellent post, ripping to pieces the rantings of this outdated lunatic who quite obviously has no intention of ever treating everyone in society equally and completely fails to engage any understanding in the subject that he has written about.

    • Thanks! It’s really disconcerting that people listen to this guy, but I guess it’s easier to listen to a self-proclaimed “expert” who just tells you what you want to hear than to step outside of the box and actually listen to people on their own terms.

      • “a self-proclaimed “expert””? Uh he’s actually a Harvard educated medical doctor who has been practicing for decades and was director of the Department of Psychiatry and Behavioral Science at the Johns Hopkins University. At the same time, he was psychiatrist-in-chief at the Johns Hopkins Hospital. You’re just some girl with a blog and an opinion… How could anyone think you are more qualified than he is to speak on this subject?

        • Well the proof is in the pudding. The fact that he fails to engage the issue with any sort of intellectual consistency overrides any credentials he may have. He is not an expert in this particular field. Him being touted as an expert is as ridiculous as Steven Hawking being taken seriously on matters of philosophy and theology because he is an expert in high level physics. I don’t claim to be a specially privileged intellect, but I can spot horrid logic for what it is.

        • Also, I could have easily countered what he has to say with every other PHD/expert in the field, pretty much all of whom disagree with him. Why didn’t I? Because fighting credentials with credentials is useless. Either he’s right or wrong, no matter what his credentials are, and no matter if every other person with credentials disagrees with him.

    • “…it seeks to align a person’s bodily structure with their neurological reality.”

      Oh, okay, so whenever there’s a difference between objective, biological reality and a patient’s inner disbelief and struggle with said reality, reality must go!! What kind of insanity are you advocating for the sake of your social cause? Is sex (I will not use your made-up, modern-day invention of gender) the single, solitary instance where this irrationality is advocated, or do you extend the subjective feelings of individuals to other areas of life as well?

      No one defending this unfortunate nonsense would for one second accept this premise when it comes to just about any other issue in life: I feel like a doctor, so I’m going to hang up my medical license obtained from The University of Photoshop. Any patients cool with this plan of mine? How about if some conniving (or confused) whitey takes a black scholarship from an enterprising, deserving African-American from the NAACP Scholarship Fund? No? Why not … using your irrationality?! If nothing means anything other than what we suppose or want, then nothing means anything anymore…it’s open season on everything. Why is sex-reassignment the lone exception to the Reality Rule – as if biological reality has nothing to say about anything … as if sex is a mere accident of nature and not an ontological, immutable reality of Man!!

      What a world of unreality you’d lead us into … all because you’re too empathetic to help the poor confused man struggle and learn to accept his sex. You’d teach the poor wretch with a shoe fetish that his urges are perfectly normal when he sees a red pair of 4-inch stillettoes, instead of pointing him toward the legitimate purpose of sexual reproduction!! Yes, apparently the individual knows best, even when the individual in question believes he’s Napoleon Bonaparte. Genuflect to the “Emperor” the next time you see him for me!!

      Anyone this detached from reality, or so intent on detaching the rest of us from obvious reality, shouldn’t be in the helping professions. He most certainly should not be in the research field. This is more like the advocacy of a snake-oil salesman.

      My favorite “scientific” line of this scholarly treatise is this whopper:

      “Those I met after surgery would tell me that the surgery and hormone treatments that had made them women had also made them happy and contented.”

      Oh, okay. There we have it: it’s settled science because you’ve met 7-9 people!! Congratulations, you’ve solved a vexing problem in about 45 minutes at a meet and greet! Man, we’ve got to get you in on the Middle East problems we’re facing, you’d figure everything out by the end of the ISIS ice breaker!! This is what goes for “serious science” from people like this. They disregard John Hopkins’ stopping all sex-reassignment surgeries because too many outcomes have been failures … and yet this author would have us believe John Hopkins is peopled by a bunch of unscientific ignoramuses – because, you know, the author has met the 7-9 people who say things are wonderful. Now that’s hard data! …Hard data to believe!!!

      Now, continue on with the echo chamber.

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  21. It is a LIE to pretend that normal, healthy chromosomes are somehow “wrong”. If you have the normal set of two sex chromosomes in your cells (XX or XY), and you somehow get the idea in your head that are supposed to be the other “gender”, then there is something wrong with your MIND, not with your chromosomes. Psychological healing is needed, not physical mutilation. It is wrong to rebel against nature. Stop LYING to yourself and others.

    Why is this big lie being shoved down our throats at every turn?

    I will be called a “bigot” and a “hater” for not stupidly buying in to the anti-nature agenda. I do not hate anyone, certainly not people who are depressed and mixed up about their identity. I would like to see them get the real help they need to discover what emotional issues are really underlying their problems. However, I am angry that people are LYING (and even now, drugging and mutilating normal, healthy, innocent children!) in order to manufacture a new class of “victim” for the progressive political machine while simultaneously viciously persecuting anyone who dares to resist their evil lies by telling the truth.

    • What about an intersex woman with a vagina but male xy chromosomes? Is she lying about being a woman even though her underlying chromosomal structure is male-typical? (see XY Gonadal Dysgenesis http://en.wikipedia.org/wiki/XY_gonadal_dysgenesis)

      Chromosomes form the blueprint, but they aren’t completely determinative. A person can have all sorts of “healthy” chromosomes in their body that encode all sorts of health problems, discordances, and inherited diseases. The idea that xx and xy chromosomes are in a special class all to themselves and are not subject to the same issues as the rest of genetics is problematic.

      And how exactly am I lying? I never claimed to have xx chromosomes (although I could, for all I know). My claim is that my gender identity – my hard-coded gendered sense of self – is female, so thus I’m transgender. This is stating a fact, not telling a lie.

      And I am not a political agenda. I’m a person. I bleed if you cut me. I wince if you insult me. I’m not a “political victim” – I’m a human being who has to go out into the world every day and face very real hatred. Even if being transgender is a disorder, that disorder should draw compassion from people, not rage.

  22. From the article titled: “Transgender Surgery Isn’t the Solution
    A drastic physical change doesn’t address underlying psycho-social troubles.”

    “A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered, evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription.”

    Your thoughts?

    • Well, I think the quote says what needs to be said right away: “This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery.”

      Surveys and follow-up studies show – and McHugh has admitted this several times – that the majority of post-op transsexuals are satisfied with their surgery. And when you look at the small percentage that report dissatisfaction, most of their reasons do NOT have to do with surgery regret, but with the fact that the surgery was botched, or it doesn’t look right, or they expected the surgery to wipe away all their problems and it didn’t. The few cases of true regret are probably from mis-diagnoses, like transvestites or people with dissasociative identity disorder who fool the medical community into diagnosing them as transsexual.

      There are two problems operating here. The first is that some people in the medical community, Paul McHugh included, believe that unless surgery is a complete cure for all problems a transsexual person has, it isn’t a worthwhile procedure. I’m not sure why anyone would think that. Genital surgery cures ONE problem: the discordance between the brain and the genitals. It does nothing else, and shouldn’t be expected to do anything else.

      The other problem is what causes transgender suicides. Multiple studies have demonstrated that transgender people across the board (before or after surgery) are more at risk for depression and suicide ideations, and those studies confirm that the cause of this increased risk is poor treatment, hate crimes, and discrimination.

      So if transgender women are still depressed after surgery, and they report it is due to loneliness, isolation, and discrimination, maybe the problem isn’t the surgery. Maybe the surgery saved them from one particular kind of depression caused by their brain and genitals being at war with each other. But surgery doesn’t fix the world around you, and transgender women still have to face loneliness in the world.

      Also, these studies have built-in limitations as they are extremely self-selecting. Transsexuals with successful post-op lives are more likely to blend into the rest of society and escape medical census, whereas the transsexuals who come forward or remain on the grid enough to be brought in for these kinds of studies are more likely to be the dissatisfied ones. I know one study in the UK (I can’t remember the year) even listed this as a known limitation.

      Some stuff to look at:

      Click to access ntds_full.pdf


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