The impact of sex reassignment surgery on sexual relationships

This short paper reviews the information on couple and sexual relationships of individuals who undergo sexual reassignment surgery (SRS). Case vignettes and anecdotal articles from transgender people and their partners were informative, not reliable. No research evidence was found on how couples managed the changes in their relationship, scant data on changes in the couple’s sexual behaviour and none on partner adjustment to the person who is transgender's physical changes.

Data was found on whether transgenders were married, with a steady partner, a number of sexual partners pre- and post-SRS and satisfaction with sexual functioning. From this it is tentatively concluded that the impact on a couple's relationship is considerable and although there was some improvement post-SRS in maintaining a steady relationship less than half of transgender people had a steady relationship.

Introduction

“Loneliness, and the inability to find partners, is one of the best-kept secrets
in the trans community…” (Wilchins 1997 cited in Lev 2004:279-280) The author sought literature on the couple and sexual relationships of individuals who undergo sexual reassignment surgery (SRS) because of interest in how couples managed the changes in their relationship, in particular, changes in sexual behaviour and partner adjustment to the transgender person's physical changes.

The American Psychiatric Association (1993, 302.85) mentions genital avoidance in its definition of Gender Identity Disorder stating that sexual activity with same-sex partners, “is generally constrained by the preference that their partners neither see nor touch their genitals” (American Psychiatric Association 1993, 302.85). What evidence was there for this statement? This was something that had been described by a Relate client in her first assessment interview (with a different therapist). What of other-sex partners; and does this behaviour change after surgery; and what other changes might there be?

The literature search included relationships, partners and post-operative follow-up studies of female to male (FtM) and male to female (MtF) transgender people; also reviews of follow-up studies. A summary of findings follows.

Findings

Data on whether transgender people achieved orgasm and on satisfaction with physical changes although interestingly, is not reported as outside the scope of this project.

Junge and Pfäfflin (1992) undertook a review of thirty years of international follow-up studies of two thousand individuals post-SRS. They note (chapter 6) that some surveys discussed partnerships and sexual experience in regard to satisfaction, dissatisfaction and/or psychosocial functioning. Many follow-up studies indicated the length of before and/or after treatment marriages. The stability and quality of the partnerships were mentioned in three studies. Two of these agreed that FtMs were more capable than MtFs to maintain stable and satisfactory partnerships.

Partnerships were researched in four studies and some follow-up studies separately researched sexual experience: four of these found that sexual experience improved statistically significantly. Junge and Pfäfflin do not mention the partner’s experience.

The Belgrade reassignment programme (Rakic et al 1996) only considered homosexual transgender people for surgery for social and legal reasons, also seeing them as “more impaired functionally” than heterosexual transgender people (Rakic et al 1996:517). They used 10 questions to follow up 32 people who are transgender, reporting that more were satisfied with their relationships and found sexual partners more easily than before surgery. More of them experienced orgasm with their partners, but they were not asked about the quality of their relationships. There was no control group, a small sample and a short follow-up period so the findings are viewed as tentative.

Green (1998) reviewed seven reports on post-operative patients and stated that “reports of sexual responsivity” are rare and that the data that is available is self-reported, not laboratory-based and studies “are limited, varying in methodology and scope” and therefore “subject to considerable distortion”. He called for laboratory-based research of all SRS procedures.

Sexual health 

Nemoto et al (1999) examined the relationships between HIV risk behaviours and social and cognitive factors among MtFs in comparison with homosexual and bisexual men, and heterosexual females. 64% of the 25 transgender sample were single, 24% married and 12% were separated/divorced/widowed. Transgender people had a higher number of sexual partners in the past six months and 30 days than the other groups, while having fewer steady relationships.

They were exposed to more risk of HIV infection and transmission for several reasons. 28% had exchanged sex for money or drugs. Engaging in receptive anal sex was more frequent with customers than with steady partners. The sample size was small, and only considered those presenting at HIV/AIDS-related services but the survey provided insights into HIV risk behaviours among transgender people, and advocated education. High rates of HIV in MtFs was also noted in (Clements-Nolle et al 2001 cited in Lawrence 2005:147).

Docter and Fleming (2001) report that 71% of 64 MtF transgender people in their study had married and 9% were living with their wives. 58% of transgender people had divorced and 4% were separated. However, the sample were volunteers, probably better educated and socio-economically than the general population and probably free of mental health issues; those not seeking help were not represented.

A follow-up study of 171 Dutch transgender people Smith et al (2002) investigated whether post-operative transgenders’ functioning improved after SRS, and whether there were differences in MtF and FtMs. Relevant to this project is that 49.5% of the follow-up sample had a stable relationship with one partner at the time of the semi-structured interview. The other 50% had no partner at follow-up or had never had one.

Lev (2004:272-279) reviewed studies that consider “partners, spouses and significant others” but much of this research was about transvestites, rather than transgender people although the findings may be similar. Lev (2004:16) comments that little discussion exists on spouses’ needs and that “transitioning within supportive families is rarely suggested”. Lev highlights the irony that relationship success is one of the criteria used to assess the success of SRS “when some clinics have insisted that clients sever their marital relationships before treatments are approved.” Historically marriage was a “contraindication to cross-sex surgery” (Randell,1971:57, Clemmensen 1990:124 cited in Lev, 2004:277).

4-stage family emergence model

Lev (2004:281-314) describes a four-stage model of family emergence: discovery and disclosure, turmoil, negotiation and finding balance. She states that “Transgendered can make compromises that will enable both partners to remain in their marriages and this can be a healthy decision for some people” (287) but, “not every couple is able to survive transition intact”. Shifting sexual identities (301) produce significant issues for sexuality. "

She proffers that literature may refer to transgender people as asexual with low libido when it may simply be the problem of finding partners who are able to deal with the complexities of gender identity, sexual orientation and sexuality. There can sometimes be spontaneous changes to sexual orientation after SRS but there was little research on the impact of sexual orientation confusion in relationships.

Lev uses vignettes to illustrate “a small sample” of sexual issues: A heterosexual woman struggles with being in a gay relationship when she needed a man as a sexual partner. A MtF person was able to act as sufficiently transmasculine while his wife extenuated her femininity thus finding some of their old heterosexual passion. A MtF was surprised after 30 years of gay relationships to be attracted to men. A transmasculine MtF who was gay who would not allow her partner to touch her genitals, after FtM transition was able to enjoy her partner touching her. A bisexual couple did not experience conflict in their sexuality; but bisexuality does not necessarily mean that they will be attracted to the man or woman their partner becomes after SRS.

Transgender people are sometimes drawn together sexually but are likely to go through the same four stages that a non-transgendered partner will experience. These examples give an overview of the challenges faced by transgender couples but is slanted to the transgender person’s perspective and are not research-based evidence.

Cuypere et al (2005) followed up 55 Dutch-speaking transgender people both MtF and FtM, to evaluate the long-term use of hormonal treatment and to evaluate sexual health. Various instruments were used to collect data. Of interest was the use of the descriptive “biographical questionnaire for transsexuals and transvestites” (Verschoor & Poortinga 1988 cited in Cuypere et al 2005:682) which has 250 fixed response category items and was used in a structured interview pre- and post-treatment.

Questions included, “Do you have a stable sexual relationship”, sex of the partner and sexual satisfaction with the partner. A further questionnaire with fixed response categories enquired about the start and length of the relationship, age of partner, sexual satisfaction, changes in sex life etc and general post-operative satisfaction. The partner’s perspective was not considered.

Cuypere et al (2005) concur with American Psychiatric Association (1993, 302.85) in finding that pre-operative transgender people often did not tolerate their genitals being touched by anybody but this improved post-SRS. Although the post-operative transgender person's expectations were “met at an emotional and social level” with 80% reporting improvement in their sexuality, they were less happy at the “physical and sexual level”.

The partner relation parameters indicated that stability of sexual relationships improved after SRS (35.3% before, 52.7% after) but FtMs had more difficulty in establishing a relationship after SRS because of their uncertainty about their maleness. When they were able to start a stable relationship they were satisfied both sexually and generally.

The response rate was lower than for some other studies, perhaps as it involved an interview but also because of address changes and unwillingness to participate. The profiles of those who did not respond could not be included in the research, an unavoidable bias. All the data was self-reported and subjective although the SRS is to correct a problem that is subjectively determined so, it was argued the use of subjective data to evaluate SRS may be acceptable.

One surgeon study 

In the same year, Lawrence (2005) published the results of a study that examined the pre- and post-SRS sexual attitudes, behaviours, and partnership patterns of 232 MtF transgender people who received SRS under one surgeon using a consistent technique. Self-administered 41 item questionnaires were used to gather data. The National Health and Social Life Survey was used as a control group.

Lawrence reviewed previous follow-up studies noting that most have not looked for detailed information about pre- and post-operative sexual behaviours. The prevalence of stable partner relationships had been considered in several studies and “roughly half of MtF transgender people” have long-term relationships. Many MtFs have had multiple sexual partners both pre- and post-SRS, while some had no partners (Lawrence 2005:149).

The questionnaire covered a wide spectrum including “whether they had been married to a woman before SRS, and whether they still lived with that person”, “whether they were currently in a ‘stable romantic or partnered relationship’” and “whether they had been in such a relationship at any time after undergoing SRS, and whether these relationships, if any, had started before SRS”. Disappointingly the study did not ask about the quality of the “stable romantic or partnered relationship”.

The comprehensive results consider sexual orientation before and after SRS, the number of sexual partners before and after SRS, frequency of sexual activity, the prevalence of autogynephilia arousal before and after SRS, frequency and characteristics of orgasm after SRS and prevalence of stable partnerships after SRS.

The number of sexual partners was also reported in each of four possible partner categories. Lawrence (2005:155) reported that 75% of those who had exclusively female partners before SRS and exclusive male partners (F/M) after SRS had been married to a woman before SRS. 96% of those who exclusively had female partners before and after SRS (F/F) were married to a woman before SRS, 9% of those who had exclusively male partners before and after SRS (M/M) were married to a woman before SRS.

62% (132) of those who answered the questionnaire had been in a stable romantic or partnered relationship at some point since SRS, for 47% of these participants this relationship had commenced before SRS. 45% were in a stable relationship and 47% of those had started their relationships a minimum of one year earlier. 71% of F/M were in stable partnered relationships after SRS at any time, and 43% in a stable partnered relationship after SRS, at the time of the survey.

86% of F/F were in stable partnered relationships after SRS at any time and 83% in stable partnered relationships after SRS at the time of the survey. 64% of M/M were in stable partnered relationships after SRS at any time, and 36% were in a stable partnered relationship after SRS at the time of the survey.

23% reported having had no sexual partners in any category since undergoing SRS. 32% of transgender participants reported no sexual partners in the previous 12 months versus 10% man and 14% women of the control group. 10% of the transgender people reported five or more partners in the previous 12 months.

Lawrence (2005:163) notes that 45% of participants were in a stable relationship when the survey ended, substantially less than the rate of partnership amongst the control group. The large percentage of subjects who reported no sexual activity in the last twelve months and the relatively low number of partnered relationships indicated that many MtF transgender people have difficulty finding partners after surgery. The number of episodes of sexual activity post-SRS was analysed but there was no pre-SRS data, nor any indication if these episodes were with the same partner as pre-SRS which would have been relevant data for the author’s purpose.

Lawrence (2005:164) critiques the limitations and generalisability of her data. Only 32% returned their questionnaires: the sample may not be representative but she concludes that biases related to response rate were probably insignificant. Also, SRS with the surgeon sampled was more expensive than in other parts of the USA. Impression management may have resulted in bias in the self-reports, in relation to the numbers of sexual partners and frequency of sexual activity.

However, she submits that socially desirable responses had not had any great effect on the self-reports. This thorough research gave informative data in terms of steady relationships and sexual functioning but did not give any insights into the partner relationship.

Zimmerman et al (2006) conducted a follow-up study that considered “the general and health-related life satisfaction” of transgender people. They concluded there is a discrepancy between the subjective satisfaction with gender identity reported and the fact that they indicate they have problems with life satisfaction. This was not investigated as the study is in German.

There are various websites that support transgender people and their partners. Although informative particularly in their relating some of the partner’s experiences, they are anecdotal comments and not research-based; also a magazine article by a transgender person's wife (Bussett 2006:90). “The person I married is still there, but with the added benefit of being more comfortable with who she is. Only the packaging has changed.” 

“You are now asked or expected to change your sexual orientation to complement the transgender person's, to be attracted to breasts and soft, hairless skin. The embrace of masculine passion now becomes the soft touch of feminine desire. 
“We have a need to be intimate with each other but I am still a "straight" woman.” 
Huebscher-Scott (2002) (i)

"She doesn’t want a woman…..she always wanted a man who was masculine and strong and supportive…..she misses that masculine touch. That tenderness that is mixed with an underlying strength.” Kim (2002)

“For me, this ‘other person’ was not my partner and I didn’t’ want to kiss her”
Beaumont Society

Summary and conclusions

The author reviewed several follow-up studies on post-operative transgender people, some of which provide reliable data however no research evidence was found on how couples managed the changes in their relationship, nor on changes in the couple’s sexual behaviour, other than the touching of genitals being more acceptable post-SRS (Cuypere 2005). In one small sample, engaging in receptive anal sex was more frequent with sex customers than with steady sex partners (Nemoto 1999). No research into partner adjustment to the transgender person’s physical changes was discovered.

The author found data on whether participants are or have been married, have a steady partner or not, and the number of sexual partners before and after SRS (Cuypere 2005; Docter and Fleming 2001; Lawrence 2005; Lev 2004; Nemoto et al 1999; Smith et al 2002). From this data, it is tentatively concluded that the impact on the couple relationship is considerable, and although there is some improvement in maintaining a steady relationship post-SRS, less than half of transgender people had a steady relationship and many MtF transgender people have difficulty finding partners.

There was little exploration of the quality of these steady relationships and no data on the partner’s position. Case vignettes and a “four-stage model of emergence” (Lev 2004) gave some insight into the relationships of post-SRS transgender people but the transgender person’s perspective is privileged and it is not quantifiable data. Nemoto et al (1999) gave glimpses into the culture of some transgender people who accessed HIV/AIDS services: 28% of their small sample had exchanged sex for money (to fund SRS) or drugs.

Though predominantly anecdotal, the magazine article (Bussett 2006) and the website support for transgender people and their partners (see references and background reading) have been helpful in discussing some of the tensions and difficulties that a couple faces when one of them undergoes SRS.

It is hypothesised that relationships that survive SRS do so because of the commitment of the couple, their adaptability and resilience, together with their ability to see the transgender person as the same person. The couple finds a new way of relating to each other sexually, that is good enough for the relationship to be sustained or they remain in the relationship with no shared sexual activity.

The author’s extensive reading has facilitated the development of knowledge and understanding of SRS and some of the societal, legal and sexual challenges that transgender people face. In relation to psychosexual therapy practice, the author feels better equipped to work with clients who might seek help either pre- or post-SRS.

In assessing a transgender person and their partner for psychosexual therapy it would be important to ask about past and impending surgical interventions, but this data is collected during an initial assessment. The History Taking workbooks Relate uses contain either opposite-sex or same-sex questions. Perhaps consideration would be needed of the language used and its suitability for a transgender person and their partner. Huebscher-Scott (2002) (ii) talks of a continuum “we are monosexuals - people who love/want to have sex with only one person, regardless of gender “ and protests ”we must fight ….for our right to resist pigeonholing”.

When considering the sexual dysfunctions that might develop in a transgender person's relationship, the author first thought of the partner’s hypo sexual desire, but on reflection, the transgender person may be equally susceptible to this, and either of the couple might have any dysfunction that is seen in heterosexual and homosexual couples. Perhaps the predisposing, maintaining and precipitating factors will be issues other than the impact of SRS. As with all clients, the transgender couple’s story will be unique but benefit may be derived from using a self-focus programme and a sensate focus programme to facilitate intimacy, thus helping them find their unique way forward.

Perhaps the author has also been through Lev’s (2004:281) four-stage model of emergence: discovery and disclosure, as articles were sought and scanned for data that would reveal the desired information; turmoil, whilst seeking robust evidence in the research projects and in struggling to make sense of the statistics that were available: negotiation, of one idea, one article, one sentence versus the next for a place in this assignment; and finally, finding balance, in the completion of the task.

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References

• American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, IV, Washington DC, American Psychiatric Association, 302.85
• BEAUMONT SOCIETY “A Wife’s Perspective”, The Beaumont Society, www.beaumontsociety.org.uk/wobs/wifesperspective.html [ Accessed 26 February 2007]
• BUSSETT, S (2006) “My Husband is Now My Wife”, In: Red Magazine, October 2006 89-90, London
• CUYPERE, G De; T’SJOEN, G; BEERTEN, R; SELVAGGI, G; SUTTER, P De; HOEBEKE, P; MONSTRY, S; VANSTEENWEGEN, A; RUBENS, R (2005) “Sexual and Physical Health After Sex Reassignment Surgery”, Archives of Sexual Behaviour, Vol 34(6) 679-690
• DOCTER, JF; FLEMING, JS (2001) “Measures of Transgender Behavior”, Behavioral Science, Vol 30(3): 255-271
• GREEN, R (1998) “Sexual functioning in post-operative transsexuals: male-to-female and female-to-male”, International Journal of Impotence Research Vol 10 (1):22-4
• HUEBSCHER-SCOTT, M (2002) (i) “Being Brave”, Available from http://www.transfamily.org/brave.htm [Accessed 12th February 2007]
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• LAWRENCE, AA (2005) “Sexuality Before and After Male-to-Female Sex Reassignment Surgery”, Archives of Sexual Behavior, Vol 34:147-166
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Background reading

• MTRA (2001) “A Partner’s Story”, Online Library, Men’s Ts Resources in Australia, Available from http://www.mtra.org.au./library/01/partner.html [Accessed 8 February 2007]
• LIVINGSTONE, T (2000) “Not as we expected”, Men’s Ts Resources in Australia, Available from http://www.mtra.org.au./family/notasweexpected.html [Accessed 8 February 2007]
• BUXTON, AP (2004) "Paths and Pitfalls: How Heterosexual Spouses Cope When Their Husbands or Wives Come Out", Journal of Couple & Relationship Therapy Vol 3 (2/3) 95-109
• BUXTON, AP (2004) "Works in Progress: How Mixed-Orientation Couples Maintain their Marriages after the Wives Come Out", Journal of Bisexuality Vol 4(1/2)
• COLE, N (1990) “Introducing My Wife to BE ALL '90 or Dorothy in the Land of Oz, Part II”, International Foundation For Gender Education Available from http://www.susans.org/reference/gfam9.html [Accessed 8 February 2007]
• http://www.ftm.org.uk [Accessed 15th February 2007]
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• LANDEN, M, WALINDER J, HAMBERT G, LUNDSTROM, B (1998) “Factors predictive of regret in sex reassignment”, Acta Psychiatrica Scandinavica, Vol 97(4):284-9.
• LAWRENCE, A A (2003) “Factors associated with satisfaction or regret following male-to-female sex reassignment surgery”, Archives of Sexual Behavior Vol 32(4):299-315
• LOTHSTEIN, LM (1980) “Sex Reassignment Surgery: Historical, Bioethical, and Theoretical Issues”, Available on http://www.susans.org/reference/lothsrs.html [Accessed 12th February 2007]
• MA, JL (1999) “Social work practice with transsexuals in Hong Kong who apply for sex
  reassignment surgery”, Social Work in Health Care, Vol 29(2):85-103
• MATE-KOLE, C; FRESCHI, M (?) “Psychiatric Aspects of Sex Reassignment Surgery” Available on http://www.sissify.com/realgirl/aspects.htm [Accessed 5 February 2007]
• MAY, K (2002) “Becoming Women: Transgendered Identities, Psychosexual Therapy and the Challenge of Metamorphosis”, Sexualities, Vol. 5(4), 449-464
• MEGERI, D, KHOOSAL, D (2007) “Anxiety and depression in males experiencing gender dysphoria”, Sexual and Relationship Therapy, Vol 22 (1) 77-81
• NEMOTO, T; LUKE, D; MAMO, L; CHING, A; PATRIA, J (1999) “HIV risk behaviours among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females”, AIDS Care, Vol 11(3):297 – 312
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• VERSCHOOR, AM; POORTINGA, J (1988) “Psychosocial differences between Dutch male and female transsexuals” Archives of Sexual Behavior, Vol 17(2):173-8