Gender Identity Disorder - American Academy of Clinical Sexologists

GENDER IDENTITY DISORDER
Pre and Post Surgery Changes - Personality Profile, Psychopathology
and Social Adjustment - a Comparative Study
by
Iris Monteiro, BSc, MSc
A dissertation submitted to the Faculty of The American Academy of
Clinical Sexologists (AACS) in partial fulfilment of the requirements of
the degree of Doctor of Philosophy
September 2010
DISSERTATION COMMITTEE
Pedro de Freitas, MD, PhD
Associate Clinical Professor - Clinical Sexology
Chairman
William A. Granzig, Ph.D., MPH
President and Professor - Clinical Sexology
James O. Walker, Ph.D.
Clinical Professor- Clinical Sexology
Approved by the Dissertation Committee
American Academy of Clinical Sexologists
September, 2010
________________________________________________
Pedro de Freitas, MD, PhD
Date
Associate Clinical Professor – Clinical Sexology
The American Academy of Clinical Sexologists
Chairman
________________________________________________
William A. Granzig, Ph.D., MPH
Date
President and Professor – Clinical Sexology
The American Academy of Clinical Sexologists
________________________________________________
James O. Walker, Ph.D.
Date
Clinical Professor – Clinical Sexology
The American Academy of Clinical Sexologists
ii
ACKNOWLEDGEMENTS
To Dr. Pedro de Freitas, to whom I owe the conceptualization of this project since the very
first moment… an unconditional acknowledgement for his orientation throughout this path,
generously sharing his experience… for his trust in me and for the continuous support and
motivation… and also for the security and endless availability, it’s remarkable!
It’s a pleasure working with you…
I’d like to express the honor of having Dr. William Granzig as a Committee member of my
Dissertation. To him, and also to Dr. James Walker, my kindest gratitude for allowing the
achievement of this project.
To Dr. Catarina Soares, for her valuable contribution with the translation of this paper…
but also a special acknowledgment for having instilled a special interest for Clinical
Sexology since the early days of my professional career, for the prodigal sharing, and work
together.
To Dr. António Lopes, who kindly cooperated in this project… for his statistical support,
for being there, and for his unlimited availability. And to my patients… without their
cooperation this work would never be possible.
Some very special words with my deepest gratitude to my Father… unity and eternal
admiration… who encouraged me with his infinitive patience, unconditional support, and
also for his friendship and trust, and for having allowed me to put some common dreams on
hold…the plan of a lifetime…
iii
To my dearest brother Diogo, for his pure and sincere smile and affection, and for his
constant encouragement… I’m so proud of you!
To Alexandra Ariana and Tânia Gandaio, my special friends, always available… To
Carolina Câmara, for her dedication and availability, essential for this work achievement.
To my friends, who kindly supported me in spite of my unavailability, for their friendship,
understanding and encouragement!
To my dear Bran… my resistances force!
This paper is dedicated to a special friend… Pedro
iv
VITA
Iris Monteiro BSc, MSc, completed her University Degree in Clinical Psychology 9
years ago in Lisbon (Portugal) and is also a trained Cognitive-Behavioral Psychotherapist.
Her activity has been developed since 2001 at the Behavioral Psychotherapy
Department at Hospital de Júlio de Matos (Lisbon) and also at the Clinical Sexology Unit,
as a member of the GID multidisciplinary team. She has worked for several years, as a
Clinical Psychologist, in “Ninho” (Institution dedicated to the social integration of female
prostitutes) and also in TAP (Portuguese Airliner) leading the “Flight Phobia” program.
She has completed various training courses in the Clinical Sexology field,
cognitive-behavioral therapies, social aptitudes, and has also done a post-graduation course
in Sexual Medicine at Lisbon Medical School.
Private clinic since 2003, both as a Clinical Psychologist, and a Clinical Sexologist.
Iris Monteiro is a Diplomate of the American Board of Sexology and is completing
her PhD with The American Academy of Clinical Sexologists (AACS).
Vice-President of “ILAS – American-Portuguese Institute of Sexology”, member of
The Portuguese Association of Behavioural and Cognitive Therapies (APTCC) and
effective member of the Portuguese Society of Clinical Sexology (SPSC).
Iris Monteiro has also completed a second BSc degree in Health Sciences, and a
Master’s Degree at the Instituto Superior de Ciências da Saúde – Egas Moniz (Portugal).
v
ABSTRACT
Introduction: Gender Identity Disorder (GID) is still a complex and poorly understood
condition. The perception that transsexuality doesn’t emerge as an isolated entity has been
discussed for the past few decades, and its experience remit us to an inherent co-morbidity.
Following Sexual Reassignment Surgery (SRS), changes at psychopathology clinical
symptoms and social adaptation level become evident, but regarding the personality profile
no solid evidence has ever been granted that could prove its modification. This gap in
scientific data on this important subject led the researcher to conduct the present study,
aiming that these orientations might contribute for a better acuity in this area of clinical
care.
Objectives: To identify the characteristics of the personality profile and structure, clinical
psychopathological symptoms, and the level of social adaptation at the Moment of Clinical
Evaluation for diagnosis confirmation. Following the analysis of the former results,
compare them, in a similar way, with those at a different Moment, following SRS,
providing evidence of changes at the Personality Profile level, Psychopathology and Social
Adaptation, in this group of Transsexuals, before and after SRS.
Material and Methods: Initially a prospective and descriptive study of a group of
transsexuals at the Moment of Clinical Evaluation, and a posterior comparative study, with
the same group of transsexuals, before and after SRS, using a non-randomized sample of
twenty two individuals with the diagnosis of Gender Identity Disorder. Besides a semistructured interview, other self-assessment instruments were used: Symptom-Check –Listvi
90 Revised (SCL-90), Sociofamily Life Questionnaire, Millon Multiaxial Clinical
Inventory - II (MCMI-II), Minnesota Multiphasic Personality Inventory – 2 (MMPI-2).
The statistical procedures were done using the Statistical Package for Social Sciences –
PASW 18 software.
Results and Conclusions: At the Moment of Clinical Evaluation, Gender Identity Disorder
does not emerge as an isolated clinical entity. After SRS, we’ve observed clinically
significant changes at various levels: psychopathological symptoms, clinical and
personality disorders, and also in social adaptation, referring to a positive evolution, with an
equilibrium and stability in various dimensions.
We’ve also found changes at the
personality profile level, in GID, after SRS. Therefore, significant changes are exhibited
when compared to the initial phase of the Sexual Reassignment Process, not only at a
psychopathological level, but also at the structure and basic personality pattern. Existence
of a better balance, at various levels, when these individuals are envisaged, and evaluated,
according to their gender identity; and, a total consistency of their gender role consistent
with their gender identity.
Key-Words: GID, pre and post surgery changes, personality profile, psychopathology,
social adjustment.
vii
TABLE OF CONTENTS
DISSERTATION APPROVAL
ii
ACKNOWLEDGEMENTS
iii
VITA
v
ABSTRACT
vi
TABLE OF CONTENTS
viii
CHAPTER 1 – INTRODUCTION
3
CHAPTER 2 – REVIEW OF RELATED LITERATURE
11
Historical Antecedents
11
Concepts
17
Sex
17
Transexualism
25
Etiology
29
Biological Factors
29
Psychological Factors
35
Diagnostic Criteria
45
The American Psychiatric Association
46
The World Health Organization
50
The Harry Benjamin International Gender Dysphoria Association’s
51
Differencial Diagnoses
52
Other Behavioural States Confused with Transsexuality
55
Incidence and Prevalence
72
viii
The Phemenology of Transsexuality
77
Evolutionary Gender Characterization
77
The Classification of Transexualism
86
Sociological Aspects
92
Family Adaptation
95
Academic and Professional Adaptation
99
Religious Issues
102
Studies of Transexualism
107
CHAPTER 3 – RESEARCH METHODOLOGY
116
Study characterization
117
Ethical considerations
117
Sample
117
Study Objectives
119
Research Hypothesis
119
Definition of Study Variables
120
Procedures
137
Statistical Methodology
137
CHAPTER 4 – PRESENTATION OF RESULTS
139
CHAPTER 5 – DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
199
Discussion
199
Conclusions
232
Recommendations
235
SELECTED BIBLIOGRAPHY
236
ix
APPENDIX A
248
The American Psychiatric Association (Portuguese Version)
APPENDIX B
252
The World Health Organization (Portuguese Version)
APPENDIX C
255
(Portuguese Version)
Appendix C-I – Informed Consent Form
Appendix C-II – Interview
Appendix C-III – Symptom-Check –List-90 Revised – SCL 90
Appendix C-VI – Beck Depression Inventory – BDI
Appendix C-V – Sociofamily Life Questionnaire
Appendix C-VI – Millon Multiaxial Clinical Inventory – MCMI-II
Appendix C-VII – Minnesota Multiphasic Personality Inventory – 2 – MMPI-2
APPENDIX D
296
Statistical Analysis – Tables
x
-2-
“Do not add days to your life, but life to your days”
Harry Benjamin
Post Sriptum
On Thursday, September 2, the Portuguese Cabinet Council approved a draft
Law of Gender Identity that will soon be debated, and hopefully approved, by the
Parliament. Both the researcher and the Chairman of this Dissertation Committee
were deeply involved, as consultants, in the genesis of this new Law.
-3-
CHAPTER ONE
INTRODUCTION
The almost general assumption that gender is at the core of self image creates
extreme difficulty in understanding how, some people, in possession of the physical
characteristics of one gender can actually wish for, and believe that, on reality they belong
the other gender. Due to social and community attitudes and to the media’s largely
incoherent and sensationalist coverage, transexuality remains a considerably poorly
understood concept. Research in this area emerges thus as necessary and pertinent for a
better understanding, and also to demystify some misconceptions and throw light upon
some issues.
With such aims in mind the present work initially focus on a theoretical approach,
and followed by a study of personality profiles and social adaptation in people who are
transsexual.
Chapter Two contains a bibliographic review which begins by an historical revision
of transexualism. The researcher has attempted to conceptualize the various notions of
gender so as to better understand the issue of transexuality.
Much controversy exists regarding the etiology of transexuality. Some etiological
factor, namely of biological and physiological nature, somehow contribute to its
development. Within this framework its etiology is multifactorial, not caused by a unique
factor. Various theoretical cogitations regarding the biological and physiological factors
subjacent to this question are portrayed with the aim of understanding its possible etiology,
which not withstanding some progress is still not possible to specifically define.
-4-
The various diagnostic aspects of Gender Identity Disorder (GID) are considered, in
as much as of essential to make a correct diagnosis and this implies a full recognition and
understanding of diagnostic criteria as well as the existing differential diagnosis. Beyond
the formulation of a correct diagnosis there is the need to verify the absence, or presence, of
a psychotic illness and/or other psychiatric co-morbidity, opposing other differential
diagnosis. There are various salient sources of the clinical criteria that allow for a correct
diagnosis and subsequent treatment of GID, namely:
i. The Diagnostic and Statistical Manual of Mental Disorders – DSM-IV-TR –
American Psychiatric Association, 2000;
ii. The Classification of Mental and Behavioral Disturbances - WHO – ICD-10, 1997
iii. The Standards of Care for Gender Identity Disorders – Harry Benjamin
International Gender Dysphoria Association – HBIGDA, 6th version, 2001 (actually
World Professional Association for Transgender Health – WPATH);
iv. Clinical Guidelines established by the Gender Identity Committee of the Portuguese
Medical Council, designated by the Ad-Hoc Committee and created in 1995:
After defining the concept of transexuality and its diagnostic criteria, other
behavioral patterns frequently confused with transexuality are discussed. These human
conditions need to be discriminated due to their totally different nature. The incidence and
prevalence of transexuality are also presented.
Further on the phenomenology of transexuality is discussed, characterizing
masculinity and feminity in their evolutionary forms, and, in parallel, according to various
theoretical assumptions.
-5-
The transsexual person faces countless sacrifices, suffering and conflicts in order to
mange to live according with the identity felt to be real. The sociological implications are
discussed with the aim of enlightening the conflicts lived through at the various levels,
namely familial, professional and religious.
At the beginning of the process of sex reassignment it is obligatory to determine the
severity of the disorder and to fully understand what exactly is the request as this may vary
from sex reassignment surgery and the need to understand the problem of gender identity
itself, considering the person’s personality and the journey through the life cycle. In truth
not all transsexuals even begin or complete the entire process of sex reassignment.
The complete sex reassignment process is not the only option for those with GID.
The dilemmas and conflicts lived by these people can lead to different types of solutions. It
is a decision to be adopted considering inherent conditions, the individual’s desires and the
support of the clinical team. Carroll (2000) refers the following as the most frequent
decisions taken:
i. Incomplete treatment – abandonment of the sex reassignment process
ii. Acceptance of the biological gender and the stereotyped role
iii. Option to live intermittently the desired gender role
iv. Option for living completely the desired gender role – complete sex reassignment
process
Initiation of a sex reassignment process implies fulfilling proceedings through
various delineated stages. In accordance with the Guidelines for Treatment of the Harry
-6-
Benjamin International Gender Dysphoria Association – HBIGDA (2001) – WPATH, the
sex reassignment process involves five basic clinical phases:
1. Making the Diagnosis – Clinical Evaluation
The correct diagnosis is a basic element of the process, and for which it is
fundamental to understand the various possible diagnosis and their clinical evolution
as the disorder suffers sequent upgrading in its categorization. For a correct and
valid diagnosis it is essential that the person undergoes two distinct clinical
assessments carried out by independent clinical centers, namely by a Clinical
Sexology specialist and a second opinion should be proffered by specialist in either
Psychiatry or Clinical Psychology.
2. Psychotherapy
Individual psychotherapy aims to evaluate the person’s desire for sex change during
life course and also post-surgery expectations regarding social, affective and
professional aspects of life and preparation of family members. It also has to
function of imparting factual knowledge regarding the whole process and in
accordance with the various therapy options taken and their various implications. It
also serves to prepare the person for the impact of hormonal therapy and surgical
procedures, consequently clarifying possible myths and expectations of obtaining
perfection in the desired surgical end points. Thus, individual counseling is a
fundamental need during the various phases of sex reassignment and
should
be
boosted once the process has ended.
Group psychotherapy is an equally important tool to enable transsexuals to face
their various problems. The aim of such groups is to facilitate communication
amongst transsexuals through the sharing of individual experiences and difficulties.
-7-
As the veil is lifted on feelings of inadequacy and isolation that mask their
individual everyday lives, people can verify that these are not unique experiences
and consequently mechanisms of identification can be built. Therefore, group work
with transsexuals basically aims to promote the discussion of the inevitable
difficulties encountered day to day at various levels, namely personal, familial,
social and professional.
3. The Real-Life Experience
The Real-Life Experience is a must as the change procedure develops and wherein
the person, during a determined time period, must live as a member of the desired
gender. The evaluation of his/her integration in the family, at work and on the street,
will be essential in the recommendation for sex reassignment surgery.
The Real-Life Experience requires that the person adopts the clothing, a name and
a social role, all in accordance with the desired gender. The aim of the Real-Life
Experience is to firstly enable total acceptance as a member of the sex opposed to
the person’s own biological one, and, secondly, to reduce the magnitude of changes
which the individual has to undergo after sex reassignment surgery, in itself
irreversible.
4. Hormone Therapy
Endocrinological therapy is continuous and its purpose is to induce feminization or
masculinization as well as the suppression of the undesired characteristics of
genetical sex (secondary sexual characteristics). Hormonal sexual reassignment
refers to administering androgens to genotypical and phenotypical women and
administering estrogens and/or progesterone to genotypical and phenotypical men,
with the purpose of promoting somatic changes that enable the person to be
-8-
physically more similar to the other genotypic sex. Hormone therapy should be
prescribed and monitored by a specialist, who, together with the individual, is able
to calculate the risk-benefits incurred. It is also a treatment involving regular series
of exams to enable a correct monitoring and supervision of hormone levels and
several other parameters..
5. Surgery
For the procedure of sex reassignment to take place it is necessary that GID has
been diagnosed, confirmed by an independent clinical team and a surgery
recommendation by the Psycho-Medical-Surgical team. Furthermore, in Portugal,
contrary to what happens in other countries, for surgery to take place, it has to be
allowed by the Ethics Committee of the Portuguese Medical Council.
Sex reassignment surgery refers to surgery of the genitalia and/or breast surgery so
that morphology is altered in such a way as to enable the person to approximate the
physical appearance of the opposite to his/her genetic sex. Accordingly, non-genital
surgery reassignment refers to surgical procedures in areas other than genitals or
breasts (nose, neck, chin, hips, amongst others) carried out with the purpose of
enabling a genetic female to look more masculine and a genetic male to look more
feminine.
Post-surgery, the individual requests the legal recognition of the new identity (name
change, rectification of birth certificate and the issuing of new personal documents). The
health team should continue to provide care and support. Again, in Portugal, contrary to
other countries, because there is no specific Law of Identity (actually being discussed at a
political level), the transsexual person requests legal recognition of his/her new status
-9-
through a lawsuit against the State; it is the State and the State alone who is the sole
guarantor of a person’s legal identity and simultaneously the only authority responsible for
civil registration services. The duration of such procedures is highly variable, but inevitably
long due essentially to bureaucratic procedures (average 2 years).
Considering the various dimensions inherent to GID it is clear that it is an area
where much research is still needed and still to be carried out, as it is abundantly clear that
transexuality remains a complex and poorly understood reality and a universe full of
uncertainty. Thus, and considering the inexistence of national publications in this field, this
research is innovative in Portugal and its purpose is to contribute for a better understanding
of transexuality in as much as it aims to provide evidence of change in the Personality,
profiles, Psychopathology and Social Adaptation between two time points: the clinical
assessment confirming the diagnosis and after sex reassignment surgery. Guidelines such as
these should be considered, providing greater acuity in the clinical services provided in this
area.
These are data which have been discussed during various decades and which equally
give rise to the perception that transexuality does not emerge as an isolated entity, but
rather gives salience to inherent co-morbidity which must be taken into account.
The investigation of psychopathology in transexuality is clearly a controversial issue
(Bozcurt, 2006). Notwithstanding existing controversy there seems to be enough consistent
evidence pointing to the existence of depression and anxiety symptoms. There also seems
- 10 -
to be some consistency in the literature regarding findings of intrapersonal conflicts,
relationship difficulties and borderline profiles.
In truth there are various substantiated theories pointing to very high levels of postsurgery satisfaction in transsexual individuals. Nevertheless effective evidence is clinical.
The presence or absence of symptoms which allow for, or not, an adequate and satisfactory
functioning is clinically assessed. And at this level, are there significant changes? And if so,
which are the changes? There is evidence for change in the levels of clinical symptoms of
psychopathology and in social adaptation post sex reassignment surgery. However,
regarding post-surgery change in personality patterns there is no solid evidence that
substantiates its change.
In face of such controversy, research in this area is deemed a real necessity. The
present study is a prospective and descriptive study of a group of transsexuals before sex
reassignment surgery. It is followed by a comparative study, the methodology of which
shall be described in Chapter Three, wherein the various parameters used for its
conceptualization are described. The comparative study aims to compare the personality
profile, the psychopathology and the social adaptation in the same group of transsexuals
before and after sex reassignment surgery. The data yielded by the pre and post surgery
comparisons will be analyzed in detail in Chapter Four enabling a subsequent discussion
and conclusions.
- 11 -
CHAPTER TWO
REVIEW OF RELATED LITERATURE
GENDER IDENTITY DISORDER
Historical Antecedents
Breton, Frohwirth and Pottiez described, in 1985, the history of Transexualism (TS)
as organized in four epochs.
The first epoch was designated as the era of the Monomanias and wherein,
according to psychiatric opinion, the individual goes through a partial delirium. However,
certain observations attributed to Esquirol indicate that TS had been previously described.
The first description of TS may be credited to Esquirolin 27, who in 1983, narrates a clinical
picture similar to TS and whom the author integrated in the Monomanias. The first known
description of a case of TS is herein fully transcribed (in Des Maladies mentales, vol I, p.
524).
“Some time ago, I cared for a twenty six year old man, who was tall, of magnificent stature,
beautiful face, and who in his first youth liked dressing as a woman. Admitted into high
society, so long as he did so as a comedy actor, he invariably chose feminine roles, at last,
and after some swift contretemps, he becomes convinced of being a woman, trying also to
convince the whole world, including his family members; It happened often that whilst at
home he would take off his clothes, arrange his hair and dress as a nymph and thus dressed
run the streets. Under my care and not withstanding this whim of spirit, M. did not lose his
reason, but occupied himself all day long, curling his hair, looking at himself in the mirror
so that his particular arrangements would look as closely as possible to those of a woman,
- 12 whose walk he imitated. One day, while walking in a park I lifted the cloth of his coat,
which he had taken much trouble to arrange. He immediately took a step back and called
me impertinent and shameless. No reasoning, no care, no regímen would ever support this
hapless”
Esquirol describes M’s state as some sort of madness, which later shall be
designated as psychosis, albeit inserted in the subclass of partial delusions.
The second epoch is characterized by the Sexual Perversions. Through the 19th
century the practice of clinical psychiatry evolved and the concept of monomanias was
abandoned. The first edition of Psicopatia Sexualis written by Kaft-Ebbingin 263, appeared
in 1869. This famous work, completed by his disciple Moll, is a veritable collection of
anomalies of human sexual behavior. Kaft-Ebbing classified paranoia and considered it to
be in the genesis of degenerecence. He also classified sexual psychophaty in a complex and
fluctuating fashion. Kraft-Ebbing deals with homosexuality exhaustively focusing on
feminity in men and virility in women. In 1877, Kraft-Ebbingin
243
used the term
“Metamorphosis Sexualis Paranoica” to designate what today is termed TS.
Westphalin
27
published Die Contare Sexualempffindung in 1970, dealing with
women who are physically women but psychologically men, hereby touching upon the
motion of trans, although an autonomous diagnosis is not contemplated.
In the beginning of the 20th century, both Magnus Hirschfeld in Germany and
Havelock Ellis in Great Britain published a sterling work and wherein both authors separate
transvestism from homosexuality.
- 13 -
In 1918, Hirschfeld Creates the Institute of Sexual Sciences, in Berlin with the aim
of studying and treating those who suffered from disturbances of sexual behavior.
Felix Abraham in his book The Sexual Perversions (1931) distinguishes ten groups
of transvestites, classifying the second group as extreme transvestites, possibly what would
be presently called TS.
The third epoch is considered to be the one which best characterizes TS. The term
Transexualism was used for the first time in 1923, by Magnus Hirshfeld in an article
entitled “Die Intersexuelle Konstitution”. Cauldweel later used it again, in 1949 in lectured
entitled Psychopathia Transsexualis.
In 1953, Benjamin and Gutheil reuse and establish the term Transexuality in a
symposium promoted by the Association for Advancement of Psychotherapy. These
authors defined transsexualism as: “a manifest feeling of an individual of a determined
gender to belong to the opposite sex, and an intense desire, frequently obsessive, of
changing his gender appearance so as to live in accordance with the image he has of
himself” (in Dictionnaire de médecine et biologie, vol. 3, p. 999)in 263.
However it is in 1954 and with Harry Benjamin, considered as “the father of
transexuality” that the designation of transexualism gains autonomy as a separate clinical
entity.
Benjamin transformed transexuality into an autonomous entity, different from
psychoses and perversions. His principal demonstration was to show that the Transexual
person is neither a fetishist transvestite nor a homosexual transvestite. According to this
authorin 44, “true transsexuals feel that they belong to the other sex, desire to function as
members of the opposite sex and not merely to look like them. For them their genital organs,
- 14 -
be they primary (testicles) or secondary (penis and others) are repulsive deformities that
must be changed by the surgeon’s knife (…)” (in The Transsexual Phenomenon). The
Transsexual Phenomenon, published in 1966, is considered to be Harry Benjamin’s greatest
work.
In 1931, the Hirschfeld Institute of Sexual Science, in Vienna, presents the first “sex
change” operation in a biological male.
Hambueger, Sturup and Iversen, precursors to Harry Benjamin, carried out the first
gender correction on an American male, in Dec. 3rd, 1952. The Daily News published the
story of the sexual reattribution and of the patient, George Jorgensen, veteran of World War
II, and who requested the surgery assuming the name of Christine Jorgensen. After the
case’s publication in 1953, the attending physicians received around 465 letters from all
over the world, sent by men and women who wanted to change sex. However most of them
did not seem to meet selection criteria. Many authors became interested in the issue of
transexuality, adopting Harry Benjamin’s form of view and proposing the same solutions.
The concept of gender identity became bond to that of transexuality when in 1966 the John
Hopkins Hospital announced the opening of its Gender Identity Clinic, whose foundation
gave impetus to the creation of other similar establishments, in various places.
The first sexual reattribution surgery carried out on a Latin American male was in
1969 (in Los Angeles the surgeon Elmer Belt had already carried out a short lasting series
of surgical sexual reattribution).
The fourth epoch corresponds to the new concept proposed by Stoller in 1964,
namely Gender Dysphoria. In the initial publications this author recognizes the distinction
- 15 -
between sex and gender, wherein sex designates that which pertains to sexuality and gender
refers to the functions of sex in social status. Stoller further defines three very important
concepts. The first defines transexualism, such as described by Benjamin and his
contemporaries, as being caused by gender identity disturbance rather than being a
disturbance of sexuality. A transsexual person’s principal claim does not concern sexuality,
but rather social status. Stoller’s second point is that amongst those males that claim the
right to cross-dress, to use hormone therapy, to undergo surgery and to change civil status
there exists a considerable number of effeminate homosexuals, fetishist transvestites and
masochists, among others; together these form a group whose claims are of sexual order
and not of social status. Stoller’s third point is that the nature of feminine transsexuality is
of a different nature as that of its masculine counterpart.
Notwithstanding transsexuality continued to be considered by many as deviant and a
perversion. (Greenson, 1964; Gelder & Marks, 1969). Within a medical context,
psychodynamic therapy aimed at trans tried to solve the underlying psychodynamic
conflicts and behavior therapy tried to recondition behavior with the aim of reducing crosssex behavior and increasing the comfort with the gender attributed at birth. The failure of
these treatments (Pauly, 1965; Cohen-Kettenis & Kuiper, 1984; Cohen-Kettenis & Gooren,
1999) together with the publication of the results of the first sex reattribution surgeries, a
new era in this field is embraced upon where sex reattribution becomes a viable option.
Thus, the preoccupation with the diagnosis of gender Identity Disturbance acquires greater
relevance from beginning of the 1960’s as demand for sex- reattribution surgery (CRS)
increased.
- 16 -
From the 1970’s onwards the focus of research on TS was largely amplified. Edged
on by the increasing visibility of the transgender movements, researchers and clinicians
developed a strong interest in the diversity of sexual issues, gender identity and gender
expression. Within the approach to transexuality studies have emerged from many fields
such as psychology (e.g., Kessler & McKenna, 1978), anthropology (e.g., Bolin, 1988),
sociology (e.g., Devor, 1997a), and the human sciences (e.g., Garber, 1992).
When the American Psychiatric Association published, in 1980, the third edition of
Diagnostic and Statistic Manual of Mental Disorders III (DSM-III) a new section on
Gender Identity Disorders was included and where in three entities were grouped:
“Transexuality”, “Gender Identity Disturbance in Childhood” and “Atypical Gender
Identity Disorder”. However and notwithstanding the fact that transexuality had thus gained
nosological recognition in the DSM-III, sexual reattribution surgery was still a subject for
professional discordance fed by what could be better designated as “medical morality”. In
the course of time DSM-III was subject to revision (DSM-III-R) and as clinicians were
better exposed to an ample variety of children, adolescents and adults suffering from sexual
identity disturbances it became clearer that patients varied largely in gravity, constancy and
natural history of their gender dysphoria. Accordingly and based on numerous reflections,
the DSM-IV, emerged in 1994, with a distinct category of Gender Identity Disorder.
The number of publications in the filed increased substantially reflecting the variety
of scientific and academic points of view in the reporting of cases, in the underlying
theories (e.g., Ekins, 1997), the transversal surveys (e.g., Nemoto, Operario, Keatley, Han
& Soma, 2004) and in the therapeutic interventions and longitudinal studies (e.g., Smith,
Van Goozen & Cohen-Kettenis, 2001; Bockting, Robinson Forberg & Scheltema, 2005).
- 17 -
In the face of a clinical reality the need for a therapeutic answer became blatant. In
many countries, the clinical approach of TS is in accordance with the Standards of Care of
the International Harry Benjamin Gender Dysphoria Association – HBIGDA. The objective
of the aforementioned standards is to disseminate the consensus of the HBIGDA regarding
psychiatric, psychological, clinical and surgical treatment of Gender Identity Disorders
(Meyer, Bockting, Cohen-Kettenis, Coleman, DiCoglio, Dever et al., 2001). Considering
the irreversible nature of surgical procedures, the standards of care due to their standardized
rigor, also allows the transsexual person an adequate understanding of and preparation for
the treatment (Vitale, 2006).
As a passing font it seems worthy to mention that in 1984, Roberta Close, the first
known Brazilian transsexual posed naked for a magazine, before undergoing sex
reattribution surgery in England. After a complex judicial process to enable her to marry,
Angela Fernandez, a Spanish transsexual, officially married Angel Romera in 2001.
Concepts
Sex
The concept of sexuality involves far more than the genitalia. Presently sex in no
longer deemed to be a mere physiological element, genetically determined and thus
unchangeable.
“A person’s sex cannot be just the remit of a balance; it is rather the result of
juxtaposition of a series of elements: genetic, chromatic, gonadal, germane, gametal or
gonocytic, internal gonophoric, external gonophoric or perineal, hormonal, somatic,
- 18 -
psychosocial” (Petitin
263
, 1976; L’ambiguité du droit face au syndrome transsexuel, in
Reveu Trimestrielle du Droit Civil). Vieira (1996), considers the concept of sex as
something of complex nature, with various components: genetic, chromatid, gonadic,
anatomic, hormonal, social, legal and psychological. Kreisler in x (in Les intersexuels avec
ambiguitè génitale), in which sex determinations are concerned, postulates:
Genetic Sex (or chromosomic)
Gonadal sex
Morphological sex (or bodily sex)
Internal genital sex
Secondary sexual characteristics
External genital sex
Civil registry sex (or legal sex)
For Stanzionein 263 (1981) gender involves “all that is innate and acquired in human
sexually especially the psychological and the cultural moment” ( Promessa ad uno studio
giuridico del transessualismo, in Probleme giuridici del transessualismo, Nápoles, ESI,
p.15).
- 19 -
According to Weiningerin 263 (1975), sexual differentiation is never complete as: “all
features of the masculine are to be found within the feminine albeit in a state of lesser
development, and vice-versa” (in Sexe et caractère, p.25).
Ruas in 1987 refers that for the conceptualization of the individual of determined
gender various elements or sexes have to be in accordance: genetic sex, gonadal sex,
somatic sex (internal and external), legal sex, educational sex and gender role, that is
behavior, and sex typed behavior. It is the consonance between all these various elements,
or sexes, that allows a person to belong to either sex. When, on the other hand, discordance
is present there arises psychological and somatic intersexualities. Thus the author points to
the various phases in the process of sexual differentiation: determination on genetic, or
chromossomatic sex: determination of gonadal sex and migration of the germ cells to the
primitive gonad and differentiation of somatic sex and a secondary sexual characteristics.
According to Benjamin (1966) anatomical or morphological sex is composed by
primary and secondary sexual characteristics. Accordingly the author considers genital sex
as a subdivision of the anatomical or morphological sex.
According to Bancroft (1989) gender manifests itself in seven different ways:
chromosomes, gonads, hormones, internal sexual organs, external genitals and secondary
sexual characteristics; gender attributed at birth (e.g., “it is a boy”) and gender identity (e.g.,
“I am a girl”). The first great manifestation of gender is signaled as chromossomatic sex, to
be found in all the cells of our bodies. Simply put, in Humankind, masculine sex is
characterized by an X and a Y (Karyotype XY), and in the female by two X chromosomes
(Karyotype XX). It is the chromosomes that determine genetic sex.
- 20 -
Fig. 1 – Diferentiation of external genitals
- 21 -
After being differentiated testis and ovaries begin to secrete sexual hormones that
will act upon two regions of embrionary tissue, namely those that will develop into the
sexual organs and those that will become the encephalic nervous system. The differences in
the male and female are conditioned by pre-natal hormonal impregnation of the brain in the
male and by the absence of sensitization in the female ( Allen Gomes, 1987).
The basic hormone for androgenizing of the brain is testosterone (Ruas, 1987).
Bancroft (1989) refers that for maculinization to take place testosterone has to be converted,
in some areas, into dehidrotestoterone (DHT) by action of 5α-redutase. When there is a 5αredutase deficiency, although testosterone is present in the tissue, but there is no conversion
into DHT whereby the external genital sex does not develop.
According to Baum (1979) brain sexual differentiation is processed in two ways:
i. The hypothalamus and the pituitary in the female show typical endocrine
function due to the occurrence of positive feedback; hence typical feminine
behavior is likely to occur.
ii. Brain defeminization does not involve positive feedback, not cyclic
hormonal action; maculinization implies male sexual behavior.
Within this perspective Ruas (1987) recognizes that masculinization of the Central
Nervous System (CNS) implies the following initial phenomena:
i. Suppression of the intrinsic behavioral and neuro-endrocrinological pattern
characteristics of the female sex (defeminization); and
ii. The reinforcement of the characteristic male pattern (masculinization).
Presently pre-natal development is focused under three perspectives, namely:
hereditary factors, environment influence during intra-uterine life and the impact of the
attitudes of those that make up the child’s significant world. Studying the relationships
- 22 -
between all these factors reveals the important impact of pre-natal development on the
subsequent phases of the evolution process of human beings (Rosa, 2000).
According to Faure – Oppenheimer (1980), no biological force explains the real
sex, considering the implicit presence of psychological factors. Gender Identity is
precocious and irreversible; “it needs to be maintained and transform the body accordingly.
Psychology is more important than biology and anatomical imperfection does not initiate
Gender Identity.”
Money’s scheme (1974, 1986)in 243 for development and sequential differentiation of
gender identity compiles all the determinants involved in a diachronic perspective:
Chromosomes
H-Y Antigens
Fetal Gonads
Fetal Hormones
Genital Dysmorphism
Brain Dysmorphism
Behavior of
Body self
others
image
Puberty Hormones
Core gender identity
Adult gender identity
Pubertal
Pubertal
Eroticism
Morphology
- 23 -
Thus Biology is not the only influencing factor on being man or woman, as the
environment is another relevant factor. Because of the neo-born baby’s anatomical gender
and corresponding civil registration, the behavior of parents, family friends and others in
school will favor the child’s identification with its own gender. Certain other elements,
such as clothing and toys, as well as signals emitted by the opposite sex, will also
contribute to identification (Allen Gomes, 1987).
Again according to Money and Tucker (1975) around the age or three the child
confirms her acknowledgement of her own gender through playing considered appropriate
to either gender. Furthermore, by the age of five/six years sexual dimorphism is
consolidated.
Pereira (1987) refers that the fundamental biological basis of sexuality, itself the
product of genetic, hormonal and embryological factors, establish the general framework
for sexual development. However just by themselves this biological basis cannot determine
the specific components of individual sexual behavior both in infancy and adulthood; rather
the biological basis defines a continuous axis of behavior patterns that may emerge in
various forms. Therefore the development of sexual behavior and sexual differentiation also
emerge as a result of psychological, social and cultural factors. The relevance attributed to
the association of social learning with cognitive aspects, according to the aforementioned
author, does not lead to the forging of the dichotomy biological vs. psychological in the
construction of gender identity. According to Zarzuelain 263 (1977) psychological gender is
formed
by
endogenous
factors
symbolized
by
somatic
components
(genetic,
endocrinological and morphological), and by exogenous factors symbolized by the social
and environmental factors (parents, school, family, friends). Psychological gender is the
- 24 -
most plastic components of gender given the fact that psychological gender may be found
in the opposing end of all other genders (Benjamin, 1966).
According to Fausto-Sterling (1999) the construction of sexuality begins with
visible anatomical structures and ends with invisible but significant activities, such as
behavior and motivations that interfere in its formation and determination.
In human beings the biological attributes of sex include genes, sexual determination,
chromossomatic sex, HY antigen, the gonads, sexual hormones, the reproduction of internal
structures, external genitalia and secondary sexual characteristics (Money & Ehrhardt,
1972; Vilain, 2000; Grumbach, Hughes & Conte, 2003; MacLaughin & Donahoe, 2004).
To distinguish individual sex and gender the terms masculine and feminine are used to
describe sex and the words boy or girl, man or woman to describe gender. Gender is
associated to masculine and feminine psychological, behavioral and social traits (Kessler &
McKenna, 1978; Ruble, Martin & Berenbaum, 2006), whilst gender role refers to behaviors,
attitudes and personality traits in a given society in a specific historical period (Ruble,
Martin & Berenbaum, 2006).
At present the definition of sex embraces five elements: genotype (genetic sex),
phenotype (physical sex), gonadic sex (gonads), psychological and social sex, wherein each
of these presents three possibilities, namely: masculine, feminine and others. However,
clothing, induced phenotype (e.g., by hormones and plastic surgery) sexual orientation and
choice of partner in sexual activity are elements also to be taken into account when
considering sexuality. When all the various elements are not in consonance then we
encounter transexuality.
- 25 -
According to Diamant-Bergerin 263 (1984) the case of transsexuals, the psychological
element characterized by the individual’s given core conviction of belonging to a gender is
in complete discordance with the remaining elements, which are of physical nature and led
to gender designation at the time of birth. The conviction of belonging to the opposite sex
to that officially attributed is unshakable and characterized by initial manifestations
symptomatic of such persevering attitude which progresses constantly and irreversibly,
escaping free will. Pettiti (1992) refers that a person’s psychosocial gender may acquire
such predominance as will lead to the wiping out of all other aspects that may contradict
this psychological and social experience.
There are many components to be considered in the determination of sex or gender.
However in the case of discordance the controversy rages as to which are the determining
factors for this.
“… it is convenient to point out that the prevalent opinion is that which considers,
in the majority of hypothesis, the greater weight of the psychological profile, even more
that structure and biology” (Perlingiere, cit by Sessaregoin 263, 1990, in El cambio de sexo y
su incidencia en las relaciones familiares).
Transexualism
In actuality characterized as Gender Identity Disorder, Benjamin (1966) described
TS as an incurable diagnostic category wherein sexual reassignment surgery is the best
treatment.
According to Lief’s (1975) “Sexual System” it is understood that sexual being
incorporates various subsystems which interact in a dynamic fashion. There are: biological
- 26 -
sex, sexual identity, gender role, sexual fantasy and sexual behaviors, ordained in a
hierarchical order and ascending integration. Optimal functioning requires coordination
between the subsystems and such is not verified in transexuality, where there is discordance
between the first and second levels, without apparent cause. Silveira Nunes (1987) states
that sex is much more than gender identity; it is also, body, fantasy and behavior; thus (un)
coordination of these vectors may potentate vulnerability – TS.
Money and Walker (1977) refer that TS is a form of unsatisfaction or gender
dysphoria. In TS, then gender identity conviction and its public manifestation, that is
gender role, are as persistently discordant in regard to anatomical sex. To these authors, the
transsexual person defines his/her condition as a conviction of belonging to the opposite
sex since childhood.
Transexualism “is the expression of the real – individual self (…) an uncommon
disorder wherein an anatomically normal person feels as a member of the opposite sex and
consequently wishes to change sex, although fully conscious of the real biological
sex“ (Stoller, 1982).
Fit Breton et al. (1985) TS is a rare mental illness wherein a normal individual is
convinced of belonging to the opposite sex. This conviction is precocious and remains
unshakable. In infancy it manifests itself in cross-sex behaviors and acquiring the
conviction at puberty or a little later, of not being a girl, or a boy, like the others.
Consequently the conviction of being a TS manifests itself in cross dressing behaviors and
by the immediate need to undergo hormonal and surgical treatments with the aim of giving
the body the appearance of the gender of conviction and claiming change in civil sex
registration. The more evident anatomical proof of biological sex becomes cause for
revulsion.
- 27 -
The TS person develops a gender identity in accordance with the biological sex
opposite to his/her own. These are people who possess a biological gender at odds with
civil gender, gender of upbringing and social gender, including given registered, or official
names and considered to belong to the opposite sex with which they identify.
The transsexual person experiences a profound and continuous discomfort with
his/her biological sex (genitals) and who whishes to change physical characteristics
including the genitals so as to give them the appearance of the sex opposite to her/his own,
and to live permanently in the desired gender role. Thus the TS will be designated as
somebody born with gender identity in opposition to biological gender and who shall
assume social and sexual roles equally opposed; the TS is also known by his/her desire to
live and to be accepted as a member of the sex opposite to his/her own biological sex.
Transexuality is not a lifestyle choice and TS do not choose the way they are; they are born
as such.
Amongst researchers, clinicians and TS themselves there is a lack of consensus
regarding sexual orientation of those with GID. Some define sexual orientation on the basis
of genetic sex (Chivers & Bailey, 2000; Lawrence, 2005), others on the basis of gender
identity (Pauly, 1990; Coleman, Bockting & Gooren, 1993), thus creating divergence and
confusion. According to DSM-IV-TR (2000) and with the Winter (2003) study in M-F TS
there is a predominance of sexual attraction for men (heterosexual). However a
considerable number of M-F TS refers sexual attraction for females (Docter & Fleming,
2001; Lawrence, 2005). Again according to DSM.IV-TR, in F-M TS there is a predominant
sexual attraction for females (heterosexual) and only a small minority refers sexual
attraction for men (Coleman et al., 1993; Chiver s & Bailey, 2000).
- 28 -
Generally, the masculine transsexual is defined by masculine biological gender,
female social and gender roles, feminine gender identity and habitually heterosexual
orientation (infrequently homo or bisexual). The feminine transsexual is of feminine
biological gender, displays masculine social and gender roles, has masculine gender
identification and usually heterosexual orientation (occasionally he can be homo or
bisexual).
Fernández-Sessarego, in 1990, refers that this abnormal duality is revealed in early
infancy and is shown through the child’s behavior through preference for child play of
opposite sex, friendships formed, gestures, preferences, the manner of walking and
expressing his/her self. The child’s reactions are usually typical of the other gender. Once
in puberty and adolescence the TS acquires greater awareness of his/her abnormality and
inner conflicts worsen (Vieira, 1996).
The term TS in exclusively applied to people with normal external genitals where
discordance can only be applied to gender identity. The category of TS does not apply to
individuals with undefined, or malformed, genitals, even if they have been educated as
belonging to the wrong gender.
It is also pertinent to refer that according to Mead (1950) the concepts of
masculinity and feminity are culture-bound variables, as are the gender roles deriving from
those concepts. There are of course transsexual individuals in other cultures and these bear
clear and distinctive characteristics shaped by their environment. The TS phenomena cut
across cultures, race, income levels and geographic regions (Ramsey, 1998). The evolution
of the very concept of transexuality enables us to observe the complex divergence of
opinion and of unknown factors.
- 29 -
Etiology
There is clearly much controversy regarding the etiology of TS and not withstanding
progress in this area, as yet it is not possible to pinpoint specific causes for such a complex
phenomenon as TS. Herein are referred theoretical cogitations, which however are not
substantiated by scientific poor evidence. The causes of TS have been examined from
biological and psychological perspectives. It continues to be an arena of controversy largely
colored by complex social and political strands making it a necessity for present dar
clinicians to be aware of such a social context. Starting with recent research in the areas of
animal behavior and evolution as well as genetic and brain dimorphism as yet more has left
the land of hypothesis (Saadeh, 2004). Nevertheless and gathering in all known data it
would seem reasonable to assume that both biological and psychological factors somehow
contribute to the development of TS, which would seem to be due to not just the cause but
to a myriad of factors.
Biological Factors
There is no single, clear evidence pointing to a biological cause for TS; nevertheless
the investigations of biological causes continue to be investigated. From the beginning of
the 90’s there has been considerable expansion on research of the biological mechanisms
subjacent to psychossomal differentiation. Various hypothesis have been considered such
as the interaction between brain development and sexual hormones or changes in
chromosomes, molecular genetics, gene behavior, prenatal sexual hormones, pre natal
maternal
stress,
maternal
immunization,
neurological
processes,
pheromones,
anthropometric and neuroanatomical bases. Some of the aforementioned dynamics have
been studied in children and adults bearers of GID, in other subjects where the dependant
- 30 -
variable is sexual orientation and in non-clinical populations (Zucker & Bradley, 1995;
Cohen-Kettenis & Gooren, 1999; Cohen-Kettenis & Pfafflin, 2003; Rahman & Wilson,
2003)
Cohen-Kettenis and Gooren (1999) refer that within a biomedical context there are
three probably causes of TS:
i. Abnormal development of perinatal endocrine levels – an excess of
androgens in the female sex and a deficiency of the same in the male;
ii. The type of feedback as the response to luteinizing hormone (LH) after
oestrogen stimulation;
iii. Sexual dyformism of the cerebral nuclei – regarding both the size and /or
the form of the hypothalamic nuclei.
Based on animal models, experimental research on sexual hormone impregnation of
the brain lead the hypothesis of inadequate brain modification at pre-natal of perinatal
stages (Carrol, 2000). The importance of prenatal androgens in the developed of gender
identity is pointed to in the adreno-genital syndrome and by androgen insensitivity as seen
in the feminizing testis syndrome (Brancroft, 1989). Such studies focus on the importance
of parental hormonal balance (Silveira Nunes, 1987).
Dornerin 99, in his studies of hormone- dependent brain differentiation concludes that
human sexual behaviour disturbances may be partly due to discordance “between genetic
sex and corresponding levels of sexual hormones at the moment of pre-natal brain
differentiation”. Dornerin 243 (1978) the same author further postulated that the necessary
ingredient for male transexuality would be a pre-natal androgen deficiency, which would
influence brain dimorphism, giving it female characteristics. However, further studies did
- 31 -
not confirm this hypothesis (Goodman, Anderson, Bullock, Sheffield, Lynch & Butt, 1985).
According to the same hypothesis androgen like hormones in greater quantities at prenatal
phase could result in changes in the functional pattern of the female foetuses thereby
facilitating on precipitating TS. In this context the opposite could also happen; namely male
foetuses undergoing neuro-functional changes due to the presence of feminizing hormones,
which in turn would lead to the development, or facilitating of a feminine identity.
Based on his own studies, Dornerin
13
concludes that homosexual men have
abnormal positive responses (positive feedback) of the luteinizing hormone. Which is even
more salient in the female brain; the author drew similar conclusions for male TS (Dorner,
1989). Thus, according to Freitas (1998) women are feminine at neural and gonadal level,
whilst the male TS are only feminine at the neural level. Again Dornerin 88, after examining
the brain of human foetuses, demonstrated the existence of a critical period of neural sexual
differentiation n humans (directly recognisable at least in the pre-optic region of the
hypothalamus) that occurs and is complete between the fourth and the seventh month of
gestation. However these studies were not replicated by Goodman et al. (1985) or by
Gooren (1986).
As already mentions, hormonal influence during pre-natal phase may alter sexual
development. Ehrhardt et al. (1985) studied women, who were exposed, at prenatal phase,
to exogenous estrogens, demonstrating that a greater proportion of these women would
breed male children with a homosexual orientation.
The correlation between male hormones, brain development and differentiation and
male and female behaviour has achieved frontline status in present day research (Saadeh,
2004).
- 32 -
It is considered as a possibility that the H-Y antigen, present in the Y chromosome,
in itself responsible for the response of the foetal gonad, is absent in male TS. However this
hypothesis has yet needed to be proven (Green, 1999). In most recent comparative studies
the absence of the H-Y antigen in the male TS and its presence in the female TS reveal
neither consistency nor specificity.
Electroencephalic disturbances or chromosomatic changes (especially Klinefelter’s
syndrome) may also be pointed to as biological markers of TS. However chromosome
studies have not shown apparent anomalies in the majority of cases (Sadeghi & Fakhrai,
2000). Nevertheless Cyran has reported the existence of causes of Klinefelter’s syndrome
(XXY) amongst male TS (Cryan & O’Donoghue, 1992). Regarding the electroencephalic
disturbances, Hoening & Kenna (1979), based on various studies, refer specifically the
incidence of epilepsy in which electoencephalic disturbances are concerned. However,
these data provide quite a limited interest, since the great majority of transsexuals do not
exhibit any changes at this somatic level (Silveira Nunes, 1987).
Anatomic studies trying to correlate the size of certain areas of the hypothalamus
(“bed nucleus of the stria terminalis”), between male transsexuals and women, have
gathered some evidence. Zhou, Hoffman, Gooren and Swaabin
145
(1995), performed a
pertinent study on a determined brain region – the hypothalamus, and they have concluded
as being smaller in women than in men. In six male transsexuals, undergoing hormone
therapy, they have shown a small hypothalamic region, similar to women. This result
supports the hypothesis of an interaction between brain development and sexual hormones,
as a path to gender identity (In A sex difference in the human brain and its relation to
transsexuality). Nevertheless, these results should be carefully interpreted; the differences
- 33 -
shown in size of a hypothalamic region could be due to the hormone therapy, as no
comparative analysis was done, before and after hormones intake.
In a more recent study (Kruijiver, Zhou, Pool, Hofman, Gooren & Swaab; 2000),
using 42 brains from patients (26 belonging to the same study of Zhou et al.,1995), revealed
that the number of neurons at the “bed nucleus of stria terminalis” level in male
transsexuals is similar to women and, in contrast, the number of neurons in a female
transsexual, is equivalent to those of a man. As a consequence, the authors have concluded
that, in transsexual patients, brain and genital differentiation goes in opposite directions and
indicated the neurobiological basis of Gender Identity Disorder.
Swaab, Chun, Kruijiver, Hofman and Ishunina (2002) refer that the differentiation
of the hypothalamus occurs around four years of age, and it depends of genetic factors and
also of prenatal hormones levels. The same correlation between male behavior and
androgens is also established by Gooren e Kruijiver (2002).
Green (2000) highlights other indirect findings, still not conclusive, that have been
suggested as biological markers., namely the preferred use of hands (reflecting organized
brain laterality before birth), with male and female transsexuals using more their left hand;
asymmetric pattern in digital prints, developed before birth, is probably influenced by
sexual steroids, in both male and female transsexuals, and differs from control groups with
men and women (Green & Young, 2001); birth order, showing homotranssexuals with
older brothers, as a similar data to that found with male homosexuals non-transsexuals
(Green, 2000); this study has been rejected by other research, suggesting biologic processes
also found in individuals with Gender Identity Disorder that diverge when compared with
control groups (Blanchard, Zucker, Bradley, & Hume, 1995; Blanchard, Zucker, CohenKettenis, Gooren & Bailey, 1996; Zucker et al. 1997), in spite of the fact there is a lack of
- 34 -
experimental support in which birth order is concerned (Gooren, 2006); and finally, M-F
transsexuals with more maternal aunts than maternal uncles, as a similar finding to that of
male homosexuals non-transsexuals (Green & Kaverne; 2000).
Rahman e Wilson, in 2003, related the evidence, in homosexuals, of sexual
hormones influence in sexual orientation, demonstrated through the analysis of the second
and fourth hand fingers. Male and female homosexuals show a lower ratio between the
second and the fourth finger when compared with heterosexuals. These data, according to
the authors, bring evidence to the action of high doses of intra-uterine androgens. In spite of
its relation with sexual orientation, this genetic influence may be also related with the
shaping of sexual identity in human beings (Saadeh, 2004).
The incident of Gender Identity Disorder in brothers, family members and even
twins (homo or heterozygous) is singular, and some reports are found in the literature,
although not conclusive, in which a genetic cause is related (Anchersen, 1956; Green &
Stoller, 1971; Stoller & Baker, 1972; Hore et al, 1973; Hyde & Kenna, 1977; Ball, 1981;
Green, 2000).
Female transexuality in homozygous twins, although extremely rare, reveals the
probable influence of genetics in the pathogenesis of this disorder. Studies on transexuality
in homozygous twins suggest that a biologic predisposition (mainly genetic) may take place
as an etiological factor in gender Identity Disorder (Sadeghi & Fakhrai, 2000).
Others paths of research have pointed out the possible genetic basis for sexual
identity. Although not analyzed the molecular genetic component in gender identity,
various studies on genetic behavior have suggested a strong hereditary dimension in the
behaviour of cross gender in sample essays in the general population (Bailey, Dunne &
Martin, 2000; Coolidge, Thede & Young, 2002; Iervolino, Hines, Golombok, Rust &
- 35 -
Plomin, 2005; Knafo, Iervolino & Plomin, 2005; Van Beijsterveldt, Hudziak, & Boomsma,
2006). However, reports from clinical trials with discordant twins relatively to Gender
Identity Disorder, have shown that genetic factors are not comprehensive in which the
variation of cross gender behavior development (Segal, 2006).
Dewing et al. (2003), have conducted a study with mice, 10,5 days after coitus,
suggesting that genetic factors should influence sexual brain differentiation, as they have
managed to identify genes which directly induce dysmorfic patterns of neuronal
development and may influence the sexual differences between male and female brains
before the action of gonadal steroid hormones (Saadeh, 2004).
Research has started to identify some independent dimensions, maybe biological,
and based on children and adults characteristics with Gender Identity Disorder (Gooren,
2006), suggesting that it might have a biological basis. There is little evidence to suggest
that prenatal hormones play an important role on that level (Meyer - Bahlburg, 2005), since
the great majority of these individuals are biologically normal. This has led some
investigators to consider other alternatives that may affect the biological paths of
psychosexual differentiation or to re-consider the prenatal hormonal theory in which
hormones play a significant influence at brain level, but not genital.
In a global perspective, studies suggest that some genetic component, or other
biological processes, may contribute to the development of Gender Identity Disorder
(American Psychological Association - APA, 2008).
Psychological Factors
Various psychosocial mechanisms thought to be associated to the genesis and
maintenance of GID has been investigated. Some have been shown to be incorrect, whilst
- 36 -
others, such as the parental response to emerging cross sex behaviour, seem to have greater
clinical and empirical support. However, the emphasis has been very much on the complex
psychosocial chain and the difficulties with the identification of the various processes and
the understanding of their various impacts. For psychosocial factors to be considered as
causes, it needs must be demonstrated that they influenced the emergence of a given crosssex behaviour in the first years of life. If this should not be so, then such factors are best
considered to be maintaining factors rather than predisposing. Thus various schools of
thought have been salient regarding the influence of psychological factors on TS.
Breton et al. (1985) refer to transexuality as a pathological state. It is neither a
fantasy nor a different way of life. It is not a delusional idea as transsexuals has none of the
clinical features of psychosis; it is not also a sexual perversion, but a disorder of identity:
the aim of the transsexual’s behaviour is not gain of erotic satisfaction but that of obtaining
a certain personal and social status.
Contrary to these mentioned authors, others such as Kraft-Ebbing and Meyer
consider that TS should be maintained in the category of the psychoses.
Kraft-Ebbingin 263 (1877) suggests that TS is a paranoid sexual metamorphosis, a
psychosis characterized by the logical organization of delusional themes built upon false
premises. The delusion, a psychiatric disturbance defined by the persistence of ideas
contrary to reality, is likewise the core belief in TS. Meyer (1979) postulates gender
dysphoria as a psychotic disturbance caused by grave intrapsychic conflicts. For Klotz in 263
the primordial cause, the very same that the courts demand that should be well defined, is
that transsexuals are not delusional. They do not deny objective reality, knowing fully well
that they possess a body in accordance with civil registry of gender, but consider that
apparent reality is not in consonance with deep reality.
- 37 -
Delayin
27
considers the conviction of the transsexual to be a circumscribed
delusional idea, very close to hypochondriacal delusions that develop in individuals in
whom maturity and narcissism dominate their psychological profile. Notwithstanding that
the majority of psychoanalysts consider TS to belong within the line of the perversions,
there are paradoxical components.
For Albyin 27, “neurosis and perversion appear, in large measure, as mechanisms
that enable to fight against castration anxiety. In TS that castration is asked for”.
Soccaridesin 243 (1970) maintains the classification of TS as a perversion and considers it to
be a defence against an intense separation anxiety. Colonain 27 shares Alby´s viewpoint, “the
transsexual’s anguish is rooted before castration anxiety. It is an archaic anguish of the
same type as psychotic anguish, and in this context it may be considered as a psychotic
prelude or as a defence against a global psychological drowning. Thus, transsexuality is an
extremely profound aspect of depersonalization, although limited as to the infraction of
exterior reality”.
Freudin
253
(1909) likewise identifies castration anxiety as the most parentally
induced component of the mental process. Freud’s theory relates to the quality of being a
male and to masculinity as one of the principal and most natural of states, with both males
and females considering being a female and femininity as less valuable (Freudin 253,1933).
However the quality of maleness or femaleness is invaded by attributes of the other gender,
so that innate bisexuality shall have consequences for both normal and abnormal
development. In boys, castration anxiety blocks what would otherwise be a tranquil path
oriented towards masculinity and heterosexuality. They are thus forced to deal with their
Oedipus conflict using techniques that avert the imagined castration. In girls the problems
emerge from start and a fight to reach femininity will ensue. The way she deals with the
- 38 -
suffering which results from having been deprived of a penis, shall determine her future
sexuality. Anatomical differences allow for conflicts amongst boys, wherein the discovery
of the creature without penis brings them nearer to the reality of the castration threat; in
girls, the observing of the real penis accentuates its absence and consequent growth in
jealousy. Still yet in this context, men are better able than women to successfully overcome
such barriers (Stoller, 1993).
Thus psychoanalytic theory is classically based on the innate bisexuality of human
beings and strengthens the relationship between castration anxiety and the Oedipus
complex in the development of masculinity and femininity (Stoller, 1982). According to
green (1974) TS could emerge from an excessive identification with the mother (symbolic
relationship).
According to Money’s model (1974, 1986)in 243 of the sequential development and
gender identity differentiation, “the necessary and complex integration of so many
biological, psychological and social determinants must necessarily offer points of
vulnerability of various kinds to the impact of pathogenic factors, themselves also of
various kinds (…) the behaviour of others may contribute to the establishment of identity
and accordingly it can be expected that the style of treatment used by society, and more
precisely by the parents, in educating the child, may assume a pathogenic influence”
(Silveira Nunes, 1987).
With the aim of illustrating the weight of socio-cultural factors, Money (1975)
reports the case of two homozygotic male twins. At the age of seven months and due to a
surgical accident one of the boys had to undergo the amputation of his penis. Because of
this the parents were advised to change the child’s legal gender and to raise him as a girl.
At 18 months the difference in both children’s behaviour was already apparent, and around
- 39 -
four years of age the amputated child’s identification with the female gender was complete.
This fact reveals the extraordinary modelling power of the environment on sexual
dimorphism.
In spite of the fact this had been the “official” version claimed by Money, reality
proved to be quite different. Unlike what Money claimed to the world, the boy never got
adapted to his new gender and this story (better saying, this scientific fraud) ended up in
tragedy. Following a second sexual reassignment surgery, as an attempt to restore his
original genetic gender, the boy committed suicide (Albuquerque, 2006).
Various authors refer that in cases of TS amongst homozygotic (HM) twins, the
social aspects as well as the family dynamics are of great, if not major, influence, in the
pathogenesis of this disturbance and go on to reject any genetic influence on the same
(Garden & Rothery, 1992; Gelder, Gath, Mayou & Cowen, 1996)in
237
. Nevertheless,
Sadeghi & Fakhrai (2000) suggest that TS is an extremely complex phenomenon wherein
the interaction between both factors, social and familial, as well as biological ones would
need to be involved for such a development to take place amongst homozygotic twins.
In accordance with the Behaviourist Model, gender identity develops through
processes of “imprinting” and “conditioning”. When failures occur in these normal
processes then gender dysphoria emerges. Quaglia (1980) suggests the existence of various
causes which may lead to failures in the process of imprinting, leading thus to the
emergence of TS:
i. Numerical or structural changes in the sex chromosomes;
ii. Poorly functioning foetal testicle;
iii. Unusual stressing of the pregnant mother;
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iv. Intake of barbiturics or anti-androgenic substances by the pregnant mother
during the critical period of brain imprinting;
v. Tissue insensitivity to male hormones;
vi. Adverse environmental factors that would harm the boy’s identification with the
paternal figure, during infancy.
In accordance with Money’s theory (1980), where he introduces biological factors
(either through hormones or cerebral sexual dimorphism), the author conceptualizes the
existence of a ‘critical period’. Within this critical period, biological, psychodynamic as
well as other variables (such as parental expectations and educational styles) influence the
development of gender identity. Once this critical period is over the same factors cease to
have any such influence.
Moneyin 243 thus elaborates a triangular perspective: nature-critical period-culture.
He thus constructed an analogy with the recognised critical period wherein genital
differentiation occurs. Based on his own results Money braved the hypothesis that such a
process as the acquisition and formation of gender identity could be compared with that of
language acquisition (Money, 1988).
The same author also considered that around the age of fifteen months the elements
of behaviour modulation needed for gender differentiation are already established.
Furthermore, through gender specific play activity, at the age of three years, the child
confirms the awareness of her own gender identity (Money, 1975).
Based on clinical evidence it seems likely that transsexuality is established before
the age of three years (Stoller, 1968; Money, 1988).
- 41 -
Another theoretical model assumes that gender identity development is
characterized by maturation of cognitive development. The first behavioural signs of
Gender Identity usually appear during the years that go from nursery to pre-primary school
(Green, 1976), corresponding, in essence, to the period where the first signs of development
of gender identity (Ruble & Martinin 279, 1998). During this period, if not before, the child
becomes amenable to the social phenotypes that typically differentiate between men and
women and initiate a self-distinctive gender process (Rabban, 1950; Paluszny et al. 1973;
Thompson, 1975; Leinbach & Fagot, 1986; Herzog, 1996; Marneffe, 1997)in 279. Cognitive
schema will lead to the shaping of the child belief of his/her own belonging to the male or
female gender. Contrary to the child who is unable to categorize herself, in the case of those
who correctly differentiated her/his own inclusion in a stereotyped gender, there is a very
early cognitive organization of the child’s preferred gender behaviours (Fagot et al., 1986;
O’Brien & Huston, 1985)in 279. In accordance with the Cognitive Model, around the age of
eleven years and coinciding with endocrine changes, gender identity is consolidated by the
formation of logical thinking operations and abstract reasoning (Gooren, 1988).
The Social Learning Theories focus on the consolidation of the differentiation of
stereotyped gender behaviours, which initiate after birth. Sexual differences are marked
early in life, coming, very possibly, from the great impact that gender has on the family,
especially the parents (Sadeghi & Fakhrai, 2000).
Sorensen and Hertoft (1980) emphasise TS as pathology of character. Using the two
types of narcissistic characters described by Reich, the authors categorize male TS with a
passive-feminine structure, and female TS with a phallic-narcissistic structure. TS with a
given intra-psychic rigidity would bear an insecure sexual identity. The male TS would
react to such a condition by emphasizing his passivity and assuming himself as a woman;
- 42 -
the female transsexual would tend to modify her exterior appearance in such a way as to
direct it towards a masculine one. Other studies allusive to character pathology in TS,
repeatedly refer to a borderline structure. However, the fact that core gender identity is
precociously established, from the age of eighteen to twenty four months, leads to the
general acceptance that it is more easily pre-ordained than the possibly post-ordained
character organization (Silveira Nunes, 1987).
According to Stoller (1985) the conviction of gender belonging is precocious,
irreversible and essential. Gender identity represents the jointure of various elements,
biological, biophysical, intra-psychic, parental and social, throughout the various stages of
the individual’s development. Stollerin
27
integrates biological, ethological and
psychoanalytic approaches, thus managing to elaborate a theory of aetiology stating:
“gender identity is constructed from birth and built from a matrix, according to the
phenomenon of imprinting and over determined by the prevalence of elements that unite the
mother and the child”. Thus, Stoller (1985) emphasises the existing symbiosis between the
child and the parent of opposed gender. Gender identity is determined before the end of the
second year and its development seems to occur in two timings:
i. Symbiotic relationship with the mother, female and feminine – proto feminine
state;
ii. Elaboration of the gender identity within a separation process of the maternal
symbiosis; this would be within a process of passive individualization in the girl,
and active in the boy, who needs must disclaim his initial proto-femininity.
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The male TS proto-femininity implies a theory of the three generations – the
transsexual’s mother, considered to be a TS manqué due to problems of her own parental
nucleus, would stimulate a fusional relationship with her son, transferring onto him her own
wishes for masculinity, but, paradoxically, not allowing him his own individualized sexual
differentiation; the father would be characterized as weak and distant from the whole
process. The child is unable to learn where the mother ends and she herself begins, thus
signing an excessive identification with the mother (Silveira Nunes, 1987). Accordingly,
Stoller (1985) refers that the parents of transsexual boys form a peculiar kind of couple: the
mother is habitually hyper protective and domineering or else, too permissive, having had
frequently wished for a child of the opposite sex. She would, herself would have had in
childhood transsexual fantasies formed because of a repressed masculine behaviour in
puberty, having to give way to the adoption of the feminine stereotypes, but without any
real sexual benefit; the father is devalued and does not serve as an identification model.
For Stoller (1985) female TS is not equal to male TS, especially regarding the
contribution of family dynamics. According to (Silveira Nunes, 1987), in female TS what
emerges is a constellation practically inverse to that found in male TS, in as much as the
mother is considered weak or depressed and the father as active or at times even brutal.
Stoller (1985) points to a feminine mother who at the time of birth, or a little later in
infancy, becomes separated, (physically or psychologically), from her daughter, frequently
because of an emotional illness, such as depression; and to a masculine father, who
however is psychologically absent in at least two areas: as a husband, he does not support
his wife when she is depressed, and as a father, he does not encourage his daughter’s
femininity. Faced with such a family pattern the child not only fills the void left by the
father, but also creates a sense of masculinity. On the one hand, the little girl becomes a
- 44 -
substitute support so as to overcome the mother’s distance, and on the other she creates her
own role – a masculine father substitute - so as to ease her loneliness caused by an
unreachable mother and an active but distant father. Thus, the continuous repetition of this
parental constellation, albeit without conflict, and then reproduced by others, reinforces the
child’s conviction of belonging to a certain gender.
The determinism of female TS suggests to Stoller (1982) that the lack of a fusional
relationship to the mother seems insufficient, and unconvincing to account for the little
girl’s systematic conditioning to masculinity, by the father. Neither is this a specific
phenomenon to TS as it equally favours female homosexuality.
Either consciously, or not, Stoller’s belief is more or less implicit regarding sex (the
biological manifestation) and gender (the social and cultural manifestation). A boy’s
feminine behaviour is based on the notion “I know that I have a male sex, but in reality I
am a girl”, pointing to two different processes – that of gender behaviour and gender
identity – awareness of, which will never be distinguished from each other, or voiced.
(Faure-Oppenheimer, 1980)
For Stoller (1982) core gender identity is an irreversible conviction, which develops
very precociously, without conflict, be it or not in accordance with biological gender, and
remains fixed for life.
According to Breton (1985), Stoller went on to modify his own definition regarding
the fixed nature of gender identity, “core sexual identity in men is not totally immutable as
previously and erroneously postulated. Rather it always carries within itself the urgent
need to regress to the original state of union with the mother”. This latter conception seems
more in consonance with the semiological variety encountered and also with the concepts
of primary and secondary TS.
- 45 -
For Breton et al (1985), whatever the causing factor of TS, it occurs as the result of
a psychological or biological process, being thus a deviation, or an anomaly in the
differentiation of gender identity. As such TS is a pathological state, within the medical
domain, as it is not a matter of choice.
For Money (1994) causality in GID subdivides into genetic, pre-natal hormonal,
post-natal social and post-puberty hormonal determinants, suggesting, “there is no single
cause for role identity… nature in itself is not responsible, as neither is education or
learning, singly. All these factors act in synchrony, complementing each other”. “It is
probably safe to state that both gender identity and sexual orientation arise from that same
combination” (Bullough & Bullough, 1993; Money, 1994).
Rublo et al. (2006) defend the transactional model of gender differentiation, wherein
the child´s gender identity is gradually built. Even admitting a biological pre-disposition,
which will affect the probability of a child adopting different degrees of typical versus
atypical gender behaviour, it is also probable that many other factors will minimize or
maximize the expression of the same. These other factors include parental response to
cross-gender behaviour, the actual phenomology of the child’s gender (Martin et al, 2002),
and scans responses to the behavioural differentiation of crossed gender Rublo et al. (2006)
Diagnostic Criteria
The Diagnostic and Statistic Manual of Mental Disorders, (American Psychiatric
Association), The Classification of Mental and Behavioural Disorders, (The World Health
Organization) and The Harry Benjamin International Gender Dysphoria Association’s
- 46 -
Standard’s of Care for Gender Identity Disorders, define the diagnostic criteria for gender
identity disorders.
Some specialists advocate the elimination, or the reformulation of the diagnosis of
Gender Identity Disturbance (Hill, Rozanski, Carfagnini & Willoughby, 2005; Lev, 2005;
Winters, 2005), alleging that the diagnosis harms transsexuals, as it stigmatizes them and
thus contributes to their marked suffering. Those in favour of the diagnosis of GID,
nevertheless argue against its definition as a mental disorder as this implies a diagnosis of
the person as such, which provokes significant suffering and hampers functioning in
various areas (Fink, 2005; Spitzer, 2005). It is specifically argued that in itself GID is
sufficiently handicapping even without social ostracism; it is made more so as all mental
disorder diagnoses are stigmatizing. To take this argument to its logical conclusion would
of course imply eliminating also all other diagnoses from the DSM. On another, more
pragmatic footing, but of extreme relevance, it needs must be pointed out that a diagnosis is
essential for the provision of the necessary health care services. As Torres (2001, 2005)
points out, GID is not a mere social or existential problem; it is, rather, a health problem
that necessitates health care resources for its treatment and diagnosis.
The American Psychiatric Association
Although various diagnoses related to gender identity problems have been included
in the DSM since 1980, the specific diagnosis of GID was introduced for the first time in
the DSM-IV (1994).
In accordance with the (DSM-IV American Psychiatric Association, 1994; DSMIV-TR American Psychiatric Association, 2000) there are two components to GID and both
- 47 -
must be present for the diagnosis to be made. There must be evidence of a strong and
persistent cross-gender identification, which consists in the wish to, or in the insistence of
belonging to, the other sex (Criterion A). It is essential for this cross-gender identification
to be more than a mere wishing to belong to the opposite sex because of perceived cultural
advantages. There must also be evidence of persistent discomfort with the person’s own
gender, or a sense of inadequacy with gender role (Criterion B). The diagnosis is not made
if the individual presents, simultaneously, a condition of physical intersex (e.g. androgen
insensitivity syndrome, congenital supra-renal hyperplasia (Criterion C). To make a
diagnosis there must be clear evidence of clinically significant suffering or impairment in
social, or professional functioning, or in other important areas of life (Criterion D).
(Appendix A)
In boys, cross-gender identification is manifest by a strong preoccupation with
typically feminine activities. They may show preference for dressing in girl or women’s
clothes, or they may improvise such type of clothing using available items when the real
thing is out of their reach. Towels, aprons or scarves are frequently used to represent long
hair, or skirts. There is a marked attraction for stereotyped feminine games and hobbies.
They particularly like playing “houses”, drawing beautiful girls and princesses and
watching television programmes or videos of their favourite female personages. Feminine
stereotyped dolls are frequently the favourite toys; and their preferred games companions
are girls. When playing “house” these boys take on female roles, frequently the mother and
often are very preoccupied with images of female fantasies. They avoid violent and
competitive sports and show little interest in cars, trucks or non aggressive, but typically
male toys. They may express the wish to become a girl, or assert that they will become
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women when hey grow-up. They may also insist on sitting to urinate and pretend not to
have a penis, by squeezing it between their legs. More rarely, boys with GID may say that
they find their penis and testicles repugnant and wish to remove them; they may assert that
they wish to have, or indeed do have, a vagina.
Girls with GID react strongly and negatively to the expectations of others (e.g.
parents), or to attempts to make them use dresses and other feminine attributes. Some may
refuse to go to school, or social events, where such clothing has to be worn. They prefer
boy’s clothing and short hair, being frequently taken for boys, by strangers; they may even
ask to be called by a male name. Their imaginary heroes are frequently powerful male
figures, such as Batman or Superman. These girls prefer boys as friends, sharing with them
interest in sport, aggressive play and traditionally male games. They show scant interest in
dolls, female clothing or typical activities. A girl with this type of disturbance may refuse to
urinate sitting. She may claim to have developed, or to develop in the future, a penis, and
refuse her breasts and menstruation. Sometimes such girls claim that they will be men when
they grow-up. They also typically manifest a strong gender-crossed identity in their gender
role, dreams and fantasies.
Adults with GID are preoccupied with their desire to live as members of the
opposite sex, which may be manifest by the intense need to adopt the other sex’s social role
and to change their appearance via hormonal and surgical procedures. Individuals with this
disturbance are not comfortable when observed by others, nor in functioning in society as a
member of the sex by which they were designated at birth. In varying degrees they adopt
the behaviour, clothing and mannerisms of the desired gender, whilst in private they may
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spend much time cross dressing and impersonating females. Many try to be known, in
public, as a member of the opposite sex. Through cross-dressing and hormonal treatment,
(plus electrolysis, in the case of men), many individuals with GID are successfully taken to
belong to the opposite sex. Their preference that their partners should neither see, nor touch,
their genitals usually restrict the sexual activity of these people, with others of their
biological gender. For some men who develop GID late in life, (sometimes after marriage),
sexual activity with their wives is accompanied by the fantasy that they are both lesbian
lovers, or that the wife is a man, and he, himself, a woman.
In adolescents, the clinical picture may be similar to the adult’s, or to the child’s,
depending very much on the person’s own level of development. Due to the typical defense
mechanisms in place, it can be more difficult to make a precise diagnosis in the adolescent.
These defenses may be even more intense if the adolescent is ambivalent as to the crossedgender identity, or if it is felt as unacceptable to the family. The adolescent may be taken
along to the clinic because the parents, or teacher’s are worried with his/her social isolation,
rejection or being made fun of by peers. In such circumstances, the diagnosis of GID
should be reserved for those who present a marked crossed-gender identification (e.g. boys
who remove their leg hair). Clarifying diagnoses in children and adolescents may require
monitoring during a large time period.
In individuals with GID, discomfort and impairment are manifest in various ways,
throughout the life cycle. In young children distress is shown by the manifestation of
unhappiness provoked by their biological sex. The preoccupation with crossed-gender
desires frequently interferes with day-to-day activities. In older children, the difficulty in
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developing relationships with same gender peers, as well as age related skills, often lead to
the refusal to attend school, because of being made fun of and the rejection of the clothing
attributed to their biological gender. In both adolescents and adults the constant
preoccupation with crossed-gender wishes frequently interferes in day-to-day life.
Relationship difficulties are common and functioning at school, or work, may be
compromised. Accordingly, there is a need to codify the disturbance based on the person’s
present age. For sexually mature individuals the following specifications can be taken as
the basis for the person’s sexual orientation:
i. Sexual attraction for men;
ii. Sexual attraction for women;
iii. Sexual attraction for both genders;
iv. Absence of sexual attraction for either sex;
In the DSM-IV (1994) and the DSM-IV-TR (2000) it is further referred GID
Without Other Specification, wherein are included categories which cannot be classified as
a specific GID. (Appendix A)
The World Health Organization
The CID-10 (World Health Organization, 1997), defines three distinctive disorders:
Transexuality, Childhood Gender Identity Disturbance and Double Role Transvestism,
which are all included in the unique category of Gender Identity Disorder in the DSM-IV
(1994) and DSM-IV-TR (2000). (Appendix B)
These disorders are, according to the CID -10 (1997) relatively uncommon and
should not be confused with non conformity with stereotyped gender role behaviours, a
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much more frequent phenomenon. It is further recommended that the diagnosis should not
be made if the individual has already reached puberty; furthermore the disorder must be
present for more than six months to warrant the diagnosis.
Within the Sexual Identity Disturbances are also included Other Disturbances of
Sexual Identity and Sexual Identity Disturbance Not Specified, but they are both poorly
developed.
Comparing the two classification systems, it is observed that the term transexuality
and childhood sexual identity disturbance are organized in separate fashion. The Double
Role Transvestism is also classified separately. In the DSM-IV (1994) and the DSM-IV-TR
(2000) there is a single category of Gender Identity Disorder which can classify children,
adolescents and adults. In this classificatory system there is a clear steering away from the
term transexualism and also a clear contemplation of the possibility that the person with
GID may have sexual attraction for either, or both, sexes.
The Harry Benjamin International Gender Dysphoria Association’s Standards of
Care
Another fundamental diagnostic reference is Guidelines for the care of Gender
Identity Disorders, 6th version (2001), published by the Harry Benjamin International
Gender Dysphoria Association (presently known as the World Professional Association for
Transgender Health –WPATH), which in the introductory notes state very clearly that the
aim of the Guidelines is to promote and coordinate consensus among international
professional organizations regarding the features of, and the management of the psychiatric,
psychological, medical and surgical treatments in gender identity disturbances. As to the
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diagnosis, the Guidelines value the DSM and the CID-10 criteria, emphasising that the term
“transgender” is an inadequate diagnosis as it is normally used out of the clinical context,
by laypeople as well as professionals, where the purpose is to informally characterize
people who present more unusual forms of gender identity.
Differential Diagnosis
Beyond the aforementioned behavioural states which may be confused with
transexuality, the specific gender ambiguities will be described
The importance of the differential diagnosis cannot be overstated, when bearing in mind
that the issuing surgery is irreversible. However, it is also true that the organic states of
intersexuality, by virtue of their clinical features, do not usually present diagnostic
difficulties.
i. Non conformity with typical gender role. In accordance with the DSM-IV-TR
(2000), the distinction between GID and gender role non-conformity lies in the
depth and predominance of the cross gender desires, interests and activities. GID
does not contemplate a child’s non-conformity with stereotyped gender roles, as for
example in the case of girls considered as tomboys, or boys with “sissy” behaviours.
Rather, GID implies a profound disturbance of the person’s sense of identity as to
masculinity or femininity. It must not be applied to qualify the child who merely
exhibits behaviour not in conformity with the cultural stereotypes of masculinity or
femininity. The diagnosis cannot be applied unless the full-blown syndrome is
present, which needs must include discomfort and difficulties.
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ii. Fetishitic Transvestism. According to the DSM-IV-TR (2000), this condition
occurs in heterosexual (or bisexual) men, for who cross-dressing has the purpose of
provoking sexual arousal. Beyond transvestism, the majority of individuals with this
condition do not refer a childhood history of cross gender behaviours. Men who
meet diagnostic criteria for GID as well for fetishistic transvestism should receive
both diagnoses. If dysphoria is present in someone with fetishitic transvestism, but
who does not meet criteria for GID, then the specification “With Gender Dysphoria
may be added. The subtype “Gender Dysphoria” allows for the clinician to note the
presence of gender dysphoria as part of the fetishistic transvestism.
iii. The Psychoses. In the schizophrenic psychoses, sometimes delusions of
undergoing sex change are expressed; these are hallucinatory experiences of sex
change. Breton (1985) considers that a filiation delusion is always subjacent to sexchange hallucinations, which, in turn, is always associated to full-blown personality
and identity changes. According to the DSM-IV-TR (2000), in schizophrenia
delusions of belonging to the other gender are rarely encountered. The insistence of
belonging to the other gender, in GID sufferers, is not considered as a delusion, as
such a belief invariably signifies that the person concerned feels as belonging to the
other sex, but of course does not believe to be so. Nevertheless very rarely
schizophrenia and GID may co-exist. However, suffering from a psychosis is
considered as a formal contra-indication for sex-reassignment surgery.
iv.
Organic
Intersexualities.
These
include
Gonadal
Digenesis,
Hermaphroditism and both Male and Female Pseudohermaphroditism.
True
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These conditions are characterized either by the absence of, or abnormal,
gonads and the most frequent forms of gonadal digenesis are Turner’s syndrome and
Kleinfelter’s Syndrome. Turner’s Syndrome implies the absence of the second
feminine chromosome (XO), wherein female hormones are not produced and gender
identity is feminine. Kleinfelter´s Syndrome is characterized by a XXY genotype;
the external genitalia, of male appearance, are usually small, with testicular atrophy
due to low androgen production. People with this disorder are usually considered to
be men.
In
True
Hermaphoditism
the
individual
presents
at
least
one
morphological contradiction, wherein gonadal tissue and the genitals are either
discordant or opposing, as both female and male tissue are present, with XX or XY
showing up in the chromatin.
Pseudohermaphroditism (PH) results because of endocrine or enzymatic
deficiencies (supra-renal hyperplasia) in individuals with normal chromosomes.
Thus, in Masculine PH at least one morphologically discordant feature is present,
there is only male gonadal tissue and XY shows in the chromatin. In Female PH,
there is only female gonadal tissue and XX is present in the chromatin.
v. Divers States. In this category, Breton (1985) includes the various forms of more
unusual forms of gender dysphoria, such as transsexual crisis, depressive
equivalents, genital dysmorphobia, impotence, the various types of marginal
perversity, suggested transsexuality and masochism.
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Gender Identity Disorder without Other Specification as defined in the DSM-IV-TR
(2000), may be applied to individuals who present GID as well as a congenital intersex
state, such as Androgen Insensivity Syndrome or Congenital Supra Renal Hyperplasia, who
may cross-dress temporarily in stressing situations, who are persistently preoccupied with
being castrated or having their penis amputated, without, however wishing to acquire the
sexual characteristics of the other gender.
Other Behavioural States Confused with Transsexuality
There are other states in the human condition, of very diverse nature, but,
nevertheless, often confused with transexuality.
Homosexuality
Filho and Pacheco (1987) define as homosexual somebody who has no desire
whatsoever to change gender, and knowing to belong either to the male or female sex,
seeks out another person of the same gender, with erotic purposes. The authors state, “when
the male homosexual postures with feminine characteristics he does so as to better attract
masculine men, even though he may have strong feminine traits in his personality”.
Albuquerque (1987) defines homosexuality as the preference for sexual behaviors,
either real or in imagination, with people of the same gender, when the possibility of choice
is available. Many homosexual men do not have female mannerisms, and there are
effeminate men who are not homosexual.
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Langevin (1983) elaborated the following presentation of the principal theories of male
homosexuality:
Theory
Experimental Evidence
Aversion to the female body
None
Aversion to coitus
None
Suffering from neurosis
None
Disturbed parents/child relationship
Present in “ailing” homosexuals
Increase in femininity and in feminine
Shown to de present in 2/3
gender role identification
Genetic predisposition
None
Feminine hormonal profile
Conflicting evidence (controlled studies
do not exist)
Pre-natal environment
Interesting, but few studies
As to the so-called determination of sexual orientation many authors argue as to
whether, or not, human beings are the product of their social and cultural environment; or
rather inherit their behavioural traits. “Surely I cannot say that I have found the gene that
determines sexual orientation (…) I can only assert that the majority of homosexuals bear a
mark in a very well defined zone of the chromosomes. It is likely, that in future the gene of
sexual inclination, shall be found there” (Hamer, 1993). Alan Sanders and colleagues
attempted to replicate Hamer´s study of the link between the Xq28 chromosome and
homosexuality, as well as investigate other possible links. In their recently published study,
where 894 heterosexual and 694 homosexual men were studied, no evidence for a sexual
orientation sex linkage was found (Schwartz, Kim, Kolundzija, Rieger & Sanders, 2010
- 57 -
Harry Benjamin and Gutheil, in 1964, turned transexualism into an autonomous
clinical entity, separate from homosexuality. (Vieira, 1996).
Lucarelliin 263 (1991) distinguishes transexualism from homosexuality, “inasmuch
as the homosexual seeks a response to his sexual stimuli from those of his own gender,
recognizing himself as a man, whishing to remain as such and even maintaining his male
characteristics…” (in Aspectos jurídicos da mudança de sexo).
Transsexuals, just as non-transsexuals do, may be sexually orientated towards men,
women, both, or neither, and just as the majority of people, experience their gender identity
(whom they feel to be) and their sexual orientation (for whom they feel erotic attraction), as
distinct and separate phenomena (Feinbloom, Fleming, Kijewski, & Schulter, 1976;
Coleman & Bockting, 1988; Coleman, Bockting, & Gooren, 1993; Docter & Prince, 1997;
Chivers & Bailey, 2000; Docter & Fleming, 2001; Bockting & Gray, 2004; Lawrence,
2005).
Simply stated, homosexuals are generally fully satisfied with their anatomical sex
and their gender identity is consonant with it.
As to transexuality, there is a general tendency to presume that, after surgery, a
heterosexual orientation will be adopted. Although this is true for the majority, it is not a
universal principle. A transsexual person may have a heterosexual, homosexual, bisexual or
even asexual, orientation. According to various studies, the transsexual person’s sexual
orientation is maintained throughout the whole process of gender reattribution (Benjamim,
1966; Blanchard, 1985; Blanchard et al., 1987; Diamond & Sigmundson, 1997)in 62. After
undergoing surgery, transsexuals undergo change at anatomical level, in their relationship
with themselves and with others, in their social status, but their sexual orientation is
presumed as stable.
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When describing sexual orientation in transsexuals, researchers and clinicians and
transsexuals themselves do not all use the same reasoning. Whilst some define the
transsexual’s sexual orientation based on gender attributed at birth (e.g., Blanchard,
Clemmensen, & Steiner, 1987; Blanchard, 1989; Chivers & Bailey, 2000; Lawrence, 2005),
others define that same orientation base on gender identity (e.g., Coleman & Bockting,
1988; Pauly, 1990; Coleman, Bockting & Gooren, 1993). The differences in classification
seem partly due to the theories regarding the analogy to be found between sexual
orientation and gender identity, which, in turn are linked to the explanatory theories of
gender dysphoria – consensus is thus inexistent. (A.P.A., 2008). Classification is
particularly controversial, because to define sexual orientation on the basis of birth
attributed gender is taken by some clinicians, and some transsexuals, as a way to invalidate
their own gender identity and efforts to achieve gender reattribution.
The observed correlations suggest, for some clinicians, that the existence of a link
between gender variation and sexual orientation, implies a biological basis. Some have
proposed that the majority of types of “gender transposition” – homosexuality, bisexuality,
transsexuality, transvestism, and other transgender phenomena – are related, inasmuch as
they may all be comprehended as varying degrees of brain masculinisation or
femininization (e.g., Pillard & Weinrich, 1987). Other researchers consider these “gender
transposition” theories as overly simplistic, emphasising as they do biological factors, with
the exclusion of cultural, familial and psychological influences (e.g., Coleman, Gooren, &
Ross, 1989). Various studies point to an extremely complex link between gender identity
and sexual orientation; such a link would seem to be of great cultural and scientific
significance and would also lead to types of transexuality based on sexual orientation (e.g.,
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Blanchard, Clemmensen, & Steiner, 1987; Blanchard, 1989; DSM-IV-TR, 2000; Lawrence,
2004; Lawrence, 2008).
Although various studies i have shown significant differences between groups of
transsexuals, it is not clear what are the causal factors for such differences, or what
typology would better explain the variations encountered in this population. Controversy
and complexity seem to be inevitable dynamics inextricably linked to transexuality; it
would also appear relevant to emphasise that, much of the polemics encountered, may be
the by-product of the divergent interests of the researchers (theoretical basis) and the
expectations of the transsexuals themselves (experience based). A way of understanding
such diversions is to understand the development of the transsexual’s identity and develop
processing models, such as was done by Devor (2004) e Rosário (2004).
Homophilia
According to Vieira (1996) the term homophilia was created in 1949 by Arent van
Santhorst, to designate an attraction for same sex people, but that does not necessarily lead
to sexual intercourse (as in Le crapouillot, 1970).
Throughout the years the term has undergone changes, and Vieira (1986) suggests
that both homophilia and homosexuality should be used as synonyms.
i
Experience studies or no sexual arousal associated to transvestism, with men (Buhrich & McConaghy, 1979;
Docter, 1988; American Psychiatric Association, 2000); age of onset and development of gender dysphoria
(Person & Ovesey, 1974; Doom, Poortinga & Verschoor, 1994); sexual orientation (Blanchard, 1985,
1989,1990, 1991, 1993; Blanchard, Clemmensen & Steiner, 1987; Lawrence, 2004); rate of non-conformity in
childhood (Bockting & Fung, 2005).
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Homophobia
In 1972, George Weinberg (in Herek, 2004) published Society and the Healthy
Homosexual, herein he introduced the term “homophobia”, defining it as a form of direct
prejudice of one group towards another. Homophobia is described as a set of negative
attitudes regarding homosexuals, such as despising, discrediting, oppressing them and
being violent to them (Vieira, 1996; Borrilo, 2000; Borrilo, 2003; Eribon & Haboury, 2003),
added to the fear of becoming homosexual (Vieira, 1996; Borrilo, 2003). Homophobia may
be understood as explicit, persistent and generalized hate, expressed by violent social
practices (Mott & Cerqueira, 2001; Leony, 2006).
Again according to Vieira (1996), prejudices, degrading games, insults, scorn and
the fear of being suspected, characterize the day-to-day of homophobic individuals. They
are also characterized by defence reactions, panic reactions and the expression of hostility
towards homosexuals, as well as an extreme care to always keep up a macho exterior (in
the case of men); all provoked by fear that, according to Herek (2004), other men “may
expose him as the owner of an insufficient masculinity”.
Bisexuality
Albuquerque (1987) defines bisexuality as the preference for romantic and sexual
partners for both sexes. Masters and Johnson (1979) suggest that sexual preference is not a
fixed trait, and Kinsey et al (1948) refers that many men go through a transitory
homosexual phase in adolescence. Thus bisexuality may be transient and take place before
the person becomes either homo or heterosexual (Vieira, 1996). Beyond being transitory,
bisexuality may also be circumstantial, occurring, for example, when a person spends a
considerable amount of time in prison. (German & Langis, 1990). Masters and Schwartz
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(1984), regarding the determination of sexual preference, point out that even if biogenetical
influences were to weigh more than environmental ones, there is no reason to believe that
such would determine its immutability.
Kinsey et al (1948) placed sexual orientation, based on hetero and homosexual
behaviour, on a six point scale, designated as Kinsey’s Scale:
0- Exclusively heterosexual
1- Predominantly heterosexual, only occasionally homosexual
2- Predominantly heterosexual, but more than occasionally homosexual
3- Equally hetero and homosexual
4- Predominantly homosexual, but more than occasionally heterosexual
5- Predominantly homosexual, only occasionally heterosexual
6- Exclusively homosexual
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In his scale, Kinsey et al. (1948, 1953) established bisexuality as situated, in
different proportions, somewhere in between exclusive heterosexuality and exclusive
homosexuality. Although it is often found in the animal kingdom, there is no evidence of it
being a universal characteristic in mankind (Albuquerque, 1987).
Masters and Johnson designate as ambisexuality, the 2, 3 and 4 groups on the
Kinsey scale. This designation implies no value judgements regarding the sexual behaviour
of others. The ambisexual behaves both as a heterosexual and a homosexual, feeling no
need to include or exclude him/herself into either category. Again according to
Albuquerque (1987), ambisexuality may signify an intermediate state from which a person
evolves towards exclusive hetero or homosexuality; alternatively ambisexuality may be
viewed as a higher level of sexual, if not social, sophistication in an evolutionary sense.
Hermaphroditism
A person, who is a hermaphrodite, or a pseudo hermaphrodite, is not a transsexual.
(Ramsey, 1998).
According to Dorland’s Medical Dictionaryin 226 (1988), the term “intersex” refers to
a person who presents a mixture, in varying degrees, of the features of each gender,
including morphology, reproductive organs and sexual behaviour. The intersex individual
presents a biological disturbance.
When a person possesses reproductive organs of both genders, that are genitals with
male and female features, the term hermaphrodite applies.
Sometimes the organ characteristics are ambiguous, especially regarding the anatomical
features. Usually both elements of the sexual apparatus are atrophied, even though in some
rare cases both are well developed (true hermaphroditism) (Vieira, 1996).
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Thus, it may be said that true hermaphroditism is a rare occurrence and that it is
characterized by the presence of both testicles an ovaries in the same individual (who can
either be 46 XX or 46XY). At the phase of genital differentiation, the foetus’s testicles are
incapable of inhibiting Muller’s ducts and stimulating Wolf’s ducts resulting in an external
genital apparatus that is a mixture of male and female components. The external genital
organs usually present a predominantly male aspect, but the cerotype is more often XX. In
adulthood, the morphology of the true hermaphrodite is similar to that of a woman.
As to male pseudo-hermaphroditism, Breton (1985), suggests that there are three
large sub-types:
i. Masculine pseudo-hermaphroditism due to testosterone deficiency. Here the
organogenesis anomalies are of varying gravity, it even being possible to
achieve a feminine phenotype. The testosterone deficiency may occur due to
anomalous testosterone synthesis or to the absence of Leydig´s cells. In this case
peripheral androgen sensitivity is normal and there are no residual Mullerian
ducts.
ii. Masculine pseudo-hermaphroditism due to deficiency of the anti- Mullerian
factor- gonophore anomaly. The absence of anti mullerian factor allows for the
formation of internal masculine and feminine organs.
iii. Masculine pseudo-hermaphroditism due to peripheral insensitivity to
androgens – two mechanisms are patent here, the anomaly of the cytocilic
receptor of androgens and the isolated a α-5 reductase. Clinically it is to be
found in a complete form, known as the feminizing testicle, and in incomplete
forms;
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In the Feminizing Testicle Syndrome (complete form), the phenotype,
the morphology and the external organs are perfectly defined. The internal
genital organs are of variable aspect, with an association of more or less genesic
elements derived from the Wollf and Muller ducts; however the presence of
testicles is a constant, be they in the place of the ovaries or in the inguinal sac.
This disturbance is only detected at puberty as menarche fails to appear, or even
later when infertility issues arise. Bearers of this anomaly develop a feminine
gender identity, notwithstanding the presence of the Y chromosome.
The incomplete forms develop clinical pictures of varying severity,
provoking many mistakes in gender identification due to ambivalent, or almost
feminine, nature of the external genitalia.
According to Barrosin 263 (1990) in masculine pseudo-hermaphroditism the testicles
are present and the Karyotype is XY; however, the external genitals seem to be both
feminine and partially masculine. This is known as the feminizing testicle syndrome and it
is provoked by an anomalous lack of sensitivity to the peripheral action of testosterone; it
could also be due to a defect in the biosynthesis of testosterone. In the case of this
syndrome the person’s character and gender identity are feminine (in Intersexualidade).
In the case of female pseudo-hermaphroditism the ovaries are normal, in what is a
genetically transmitted disturbance, wherein the anomalous functioning of the supra-renal
glands produces high levels of testosterone during the pre-natal life. Its origin is not
gonadal.
Trimmer (1981) refers that the karyotype is 46XX but the external organs are
masculine, due to an autosomatic, recessive, genetic anomaly which interferes with cortisol
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synthesis, thus provoking a large production of testosterone. The internal sexual organs
remain feminine due to the absence of the testicular factor, which would inhibit the
development of the Mullerian ducts. These persist, as in the normal female fetus, leading to
the development of the uterus, the Fallopian tubes and the proximal vagina.
When, at birth, girls who are bearers of this syndrome, are designated as belonging
to the male gender, and educated as such, their gender identity and role are masculine.
However when considered, at birth to be female, their gender identity becomes feminine,
notwithstanding their pre-natal androgenization.
The sexual differentiation anomalies depend on the gravity and on the moment of
occurrence during foetal life. In the cases of hermaphroditism and pseudo-hermaphroditism
there exists a situation of sexual ambiguity; whereas in transsexuality the attribution of
anatomical sex at birth is crystal clear. The birth factor does not imply true gender
definition, as gender personality needs a greater period of maturation (Vieira, 1996).
Intersexuality is similar to transsexuality inasmuch as in both conditions the
concerned individuals experience gender confusion. They feel alone, displaced, depressed
and frustrated. Both in transsexuality as in intersexuality, the sufferers are not satisfied with
their biological gender state, present gender dysphoria and seek many of the same, or
similar, surgical or hormonal solutions (Ramsey, 1998).
Fetishism
Fetishism is considered to be a paraphilia, wherein the individual feels erotic
attraction for certain objects or materials. Possession, or handling of the fetish, or fetish
object, leads to sexual arousal and pleasure (Gillan & Gillan, 2001).
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According to the Diagnostic and Statistic Manual of Mental Disturbances (DSM-IVTR, 2000) the paraphilic focus, for the fetishistic person, implies the use of inanimate
objects, amongst which are to be usually found underwear, shoes and other items of
clothing. The individual often masturbates whilst holding, rubbing or smelling the fetish; he
may also ask his partner to wear the fetish object during their sexual encounters.
There is a general agreement that fetishism is rare amongst women (Kinsey et al,
1953).
Bancroft (1989) suggests the fetishes can be divided into three main types, namely:
body parts; inanimate objects and specific textures.
In this context, Vieira (1996) refers that the smell, the shape as well as the texture of
the fetish objects are also of great importance. In some cases, body parts such as feet, hands,
thighs, hair, beard, and tattoos, amongst others, may substitute the whole person.
Transvestism
Transvestism is characterized by the deliberate use of clothing (and accessories)
culturally deemed as belonging to the opposite sex, and it is engaged in with a two aims,
which often merge: sexual arousal and the public declaration of belonging to the other
gender (Benjamin, 1966).
Bardenain
27
(1984) refers that “transvestism consists in the use of clothes which
usually distinguish a person as belonging either to a social class, or gender, which are not
his/her own.”
Singerin 27 describes the transvestite as a heterosexual man who uses one or more,
items of female clothing so as to feel sexual arousal, either in masturbation, or with a more,
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or less, consenting partner within pre-established scenery. There is no patent wish to
change sex and the penis is often a source of pleasure.
Stoller (1987) suggests that the transvestite was often worshipped, as a child, and
whose parents tended to model him/her in accordance with precise, preconceived, projects.
Another component, often suggested by the same author, is the experience of conflicts
resulting from an absent father; when there are sisters, the child notices that they get on
very well with the mother, who does not occupy herself very much with him. Thus, the
child reasons that women have greater possibilities than men, and accordingly develops the
idea that it may be interesting to possess both strands. In adulthood, the various possible
ways of using feminine behavior emerge, leading to impulses to transvestite, to become
extremely feminine, without the need to change sex.
Viera (1996) further suggests two types of transvestites: the domestic and the public.
The domestic is considered as clandestine, frequently of the male gender, which dresses
and uses cosmetics, just like women, when he is alone. If married, he may be so very
skilled and organized as to have avoided, for years, the eruption of marital conflicts should
his “private theatre” be discovered. The public transvestite is usually ostentatious and
wishes to be taken by others as a female.
Marques Reisin
263
(1993) states that the transvestites behavior only serves to
reinforce Freud’s theory of man’s innate bisexuality, but living in accordance with the rules
and values imposed by society.
Transvestism is not a state or a tendency, rather a behavior that can manifest
different purposes as well as a deviant sexuality as seen in these cases of transvestism.
According to the DSM-IV-TR (2000), in fetishistic transvestism the focus of the paraphilia
implies transvestite behavior, which is only described in heterosexual, and occasionally
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bisexual, men. In these cases the men possess a collection of feminine clothes which are
intermittently used for transvestite purposes. Once cross-dressed, masturbation habitually
takes place, with the transvestite imagining himself both as the male, and female object of
his sexual fantasy. Vieira (1996) asserts that what differentiates the transvestite from the
fetishist is the source of arousal. For the transvestite, cross gender identification is far more
important than any possible attachment to specific garments. Transvestism is a complex
phenomenon, combining both exhibitionistic and fetishistic elements. The transvestite may
lead a perfectly normal professional life, in consonance with his gender, and outside of the
work environment openly cross dress.
Cross dressing with the aim of obtaining sexual pleasure is, in itself, a perfectly safe
activity. It can nevertheless cause public alarm when these people are caught, for example,
in female toilets, although, again, such behavior poses danger to nobody. Transvestism is
considered to be a secret sexual behavior, which is only discovered by accident (Gillan &
Gillan, 2001).
Vieira (1996) differentiates transvestism from transsexuality. The transsexual is
most unhappy, but can slightly alleviate that unhappiness wearing garments of the gender to
which he deems to truly belong. Furthermore, he/she wants to undergo sex reassignment
surgery because of sincerely believing that he/she belongs to the opposite gender, contrary
to the transvestite, who does not wish for surgery, as his sex is a source of pleasure rather
than shame.
Unlike the transvestite, the transsexual does not usually derive sexual pleasure from
wearing cross gender garments; neither is there any identification with the sexual organs
he/she was born with.
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Ramsey (1998) enumerates various differences between the cross-dressing
transsexual and the transvestite:
i. When the transsexual cross-dresses it is done fully, from head to toe. The
fetishistic transvestite usually does not cross-dress completely; it is done
partially, focusing, for example, on underwear;
ii. Usually the transsexual does not cross-dress for the purpose of deriving
sexual pleasure. The majority of transsexuals have actually very low libido;
iii. Transvestites usually spend a very significant part of their lives dressed in
a gender appropriate manner. The mature transsexual does not change role,
rather he adopts a permanent one;
iv. Transvestites like sexual self-stimulation, whereas the majority of
transsexuals cannot abide their genitals and their secondary sexual
characteristics.
The Drag Queen
The Drag Queen phenomenon began to emerge towards the end of the 1980´s in the
great urban centres, such as London and New York. Drag Queens are not transvestites, do
not undergo silicon applications, nor take hormones and are not prostitutes. They are
considered to be men who dress as women with the purpose of frequenting nocturnal
haunts; they do not wish to impersonate women, just to enjoy themselves. Drag Queens
always portray women that are glamorous, fashionable, up to the latest fashion tendencies
and always highly exaggerated (Vieira, 1996).
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Transformism
Transformers can be described as artists who cross-dress to impersonate a personage.
Unlike transvestites, these individuals cross-dress as a theatrical practice, and whilst doing
so, is neither seeking cross-gender identification nor sexual gratification.
Cross-Dressers
According to Vieira (1996), Cross-Dressers are not as exaggerated as Drag Queens.
They are identified as elegantly crossed-dressed individuals, who attend clubs catering for
such tastes, and who consider them to be heterosexual.
Daddy-Boys
Considered to be a phenomenon, in the United States of America, since 1991,
Daddy-Boys or Female-to-Male identify themselves, sexually and psychologically, as
males. Born as females, these women take hormones and impersonate homosexual men.
Unlike female transsexuals, these FTM feel erotically attracted to homosexual men (Vieira,
1996).
Shemales
Nowadays the word shemale is used in men who change their secondary sexual
characteristics, making them feminine, through female hormones intake, and also some
aesthetic surgery, but keeping their male genitals intact. These individuals have no
discomfort with their genitals, much on the contrary, it usually makes part of an adopted
life style, involved in pornography or prostitution (Wolfradt & Neumann, 2001), with
subsequent secondary professional advantage.
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A study conducted by Blanchard and Collins, in 1993, on the incidence of men
sexually attracted to transvestites, transsexuals and feminine men, reports this desire,
designated by the authors as gynandromorphophylia, and it’s more common than expected,
with a well targeted market, as porno magazines, street prostitution, and through adverts
published in newspapers.
It’s a condition described as a way to sell pornography to heterosexual men, without
triggering homophobia, or helping men to overcome their homophobia (Lynn, 2007), even
allowing a sexual interaction to egodystonic homosexuals.
Used since mid 19th century, the Shemale was faced as a reference to aggressive
women. Today, according to Weinberg and William, (2009), it’s a pejorative term, usually
used to address M-F transsexuals, with male genitals and with breasts through breast
implants and hormone therapy, and considered offensive by those who suffer from Gender
Identity Disorder. In spite of the confusion with M-F transsexuals, they don’t wish a sexual
reassignment surgery as they don’t exhibit discomfort or inter-subjective conflict with their
genitals. They keep the ambiguity features of this transgender behavior, of female outfit
with male genitals. Nevertheless, Bailey (2003), Olsson and Moller (2006) refer that some
clinicians use this category to specifically mention M-F transsexuals, in which a degree of
feminization has occurred, but not a sexual reassignment surgery.
In Shemales, the ideal feminine gender role is followed without the need of a female
complete anatomy (Lippa, 2001; Green, 1998), with a special sexual identity (Broad, 2002;
Ringo & Ringo, 2002), and belonging to a special group, different from homosexuality.
They socially exhibit a feminine look, a stereotypically feminine behavior, but with a
common denial of being a woman or having a female gender identity. They believe they
don’t fit in any of the two gender categories, male or female, sometimes describe
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themselves as the third sex and/or gender, or simply “other”. This composed identity,
neither purely masculine nor feminine, is considered as a source of proud and fulfilment by
them. Although some express a female identity, there’s still no scientific evidence that if a
stable gender identity through the time really exist (Lippa, 2001).
Incidence and Prevalence
Gender Identity Disorder is a rare occurrence, and the number of affected
individuals who seek gender reassignment surgery is largely dependent on social
acceptance, legal rights and treatment viability.
The incidence of GID is regarded as tending to remain constant, whilst prevalence
shows a great variation since the first to the most recent studies, diverging among countries
and even different epochs within the same country. The ratio between male and female
transsexuals seemed to remain constantly stable at 3:1, independently of country and epoch
(Bancroft, 1989; Ferreira, 2000). However, more recent studies do question these values.
Silveira Nunes (1987) argues that “it is not possible to present reasonable incidence
data; as to prevalence; on the contrary, there is a satisfactory consonance between the
various statistical data, from divers countries and epochs”. Kaplan and Sadock (1998) refer
that the prevalence of GID is unknown, but rare, especially among women.
Pauly in 243 (1969), estimated a prevalence of 1:100.000 and 1:400.000 in male and
in female transsexuals, respectively. Walinderin
105
(1971) points to a prevalence of
1:37.000 in M-F transsexuals and 1:103.000 F-M transsexuals. Similar values were
presented by Hoenig and Kenna (1974). O´Gormanin 243 (1982) refers the prevalence in a
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very small population, namely that of Northern Ireland, of 1:52.000 with a 3:1 male to
female ratio.
A study carried out by Eklund, Gooren e Bezemerin 105 (1988), on the prevalence of
transsexuality, estimates the following:
i. in M-F transsexuals
1:45.000 in 1980;
1:26.000 in 1983;
1:18.000 in 1986.
ii. in F-M transsexuals
1:200.000 in 1980;
1:100.000 in 1983;
1:54.000 in 1986.
In 1993, Bakker, Kesteren, Gooren e Bezemerin
43
estimated that approximately
1:11.000 M-F transsexuals and 1:30.000 F-M transsexuals seeked treatment in specialist
clinics.
According to the DSM-IV (1994) the estimated prevalence of adult cases of
transexuality seeking sex reassignment surgery is 1:30.000 in the male sex, and 1:100.00 in
the female sex.
In Ramsey’s opinion (1998) the number of biological men and women who
experience transexuality is approximately equal, (i.e. the occurrence of transsexuals
corresponds directly to the number of men and women in the general population).
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A review of data from various European countries suggests an annual incidence rate
which varies from 0.15 to 1.58 in 100.000 (Van Kesteren, Gooren & Megens, 1996; Olsson
& Moller, 2003).
Landén et al in a 1996 review discuss the variations encountered and conclude that:
i. Prevalence approximates the values forwarded by DSM-IV;
ii. Incidence remains practically the same, between 0.15 and 0.17:100.000
inhabitants above 15 years of age;
iii. The proportion between men and women varies between 1:1 amongst
male and primary female transsexuals, to 4:1 between men and women
within groups of uncertain diagnoses;
iv. The total proportion of people who seek assessment for the purpose of
sex reassignment surgery would be around 1.7:1 between men and women
from the general sample.
The conclusions of the Landén et al (1996) study seem to be consistent and adequate
with reality, in general. However, the Herman-Jeglinska et al. study (2002), states that
“differently from western countries, in Poland, M-F transexuality is much less common
than F-M”, wherein the proportion is 1:3, 4; that is one male transsexual for every 3, 4
female transsexuals. Other authors reinforce this reality, asserting that M-F transexuality is
1.5 to 3 times more prevalent than F-M (Bakker et al., 1993; Wilson, Sharp & Carr, 1999;
Garrels et al., 2000; Olsson & Moller, 2003).
In accordance with the DSM-IV-TR (2000) There are no recent epidemiological
studies to provide data on prevalence of Gender Identity Disorder. Data from smaller
countries in Europe with access to total population statistics and referrals suggest that
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roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment
surgery. The Harry Benjamin International Association for Gender Dysphoria, Guidelines
for Care of Gender Identity Disturbances, 6th version (2001), presents identical numbers to
those in DSM-IV-TR (2000), and states that the prevalence of transexuality, understood as
the distal end of the gender identity disturbances spectrum, is 1:37.000 in men and
1:107.000 in women. The reason for the greater M-F incidence remains unknown, although
some authors speculate that this occurs because comparing the definition of male gender
role with female gender role, the latter favors non-conformist females’ greater freedom to
integrate expressions of cross-gender role. (Hiestand & Levitt, 2005). Others propose that
the observed difference reflects the fact that for a proportion of M-F transsexuals, GID
derives from a fetishistic transvestism (Blanchard, 1989; Levine, 1993; Lawrence, 2003).
Notwithstanding the diverging opinions, the sex ratio tends to remain stable between 3:1
and 2:1 (Silveira Nunes, 1987). In child clinical samples, the data differ slightly. For
Zucker e Greenin 47 (1992) there are approximately five or six boys to one girl. Although
cross-gender behaviors are more common amongst girls than boys, in the general
population (Cole, Zucker & Bradley, 1982; Zucker, 1985; Sandberg, Meyer-Bahlburg,
Ehrhardt & Yager, 1993), boys are mentioned with greater frequency regarding gender
identity concerns (Cohen-Kettenis et al, 2003). According to the DSM-IV-TR (2000),
available date refer that boys are more frequently referenced for assessment, than girls,
whilst in adulthood are referred 2 to 3 times more frequently than women. In children, the
deviation in male referrals comparing to adult men, may, in part, reflect the greater stigma
that gender-cross behavior implies for boys (DSM-IV-TR, 2000). Another important aspect
in understanding the apparent gender discrepancy, refers to the gender reassignment
surgery itself, which being always an extremely complex technical procedure, it is
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nevertheless considerably less so in M-F surgery (Ramsey, 1998). For Stoller (1987),
“transexualism is much rarer in girls than in boys, because it is more plausible for there to
be an excessively close mother, than an absent mother, or an excessively close father”.
Herman-Jeglinska, Guabowska and Dulko (2002) organized the data from studies in
various countries/100.000 inhabitants, on the annual incidence of cases of transexuality in
people with age equal or superior to 15 years.
Sweden (1967 – 1970)
Incidence
T.M-F/T.F-M
0.15
1:1
0.17
1.4:1
Walinder (1971)
Sweden (1972 – 1992)
Landén et al. (1996)
(1972-2002)
2:1
Olsson & Moller (2003)
Netherlands (1975 – 1992)
0.52
3:1
0.58
5:1
0.21-0.24
2.3:1
0.26
1:3.4
Van Kesteren et al. (1996)
Australia (1976 - 1978)
Ross et al. (1981)
Germany (1981 - 1990)ii
Weitze & Osburg (1996)
Poland (1980 - 1998)
Dulko (2000)iii
According to Ramsey (1998) if the numbers referred to in the DSM-IV (1994) are
correct, there would be approximately 4500 male transsexuals and 1350 female
transsexuals in the United States of America. The exact numbers are unknown in Portugal;
ii
iii
Annual incidence of Transexualism / 100.000 of adult population.
Unpublished study.
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however an estimated extrapolation from the DSM-IV-TR (2000) numbers would place the
numbers of male transsexuals as approximately 157, and females as 53. Nevertheless, these
extrapolated numbers have never been verified, and unlike the reports from many countries,
in Portugal there are a greater number of Female-to-Male transsexuals seeking sex
reassignment surgery, with the caveat that in the last few years the number of male and
female transsexuals seeking surgery has equalized.
The Phenomenology of Transsexuality
Evolutionary Gender Characterization
According to Ramsey (1998), the behavior, attitudes and verbalizations of gender
dysphoric individuals vary throughout the life cycle. The transsexual’s path from infancy to
adulthood is marked by instability, abrupt events, highs and lows, and setbacks.
For children who attend clinics, the emergence of cross-gender interests and
activities usually emerge between the age of two and four years, with some parents
reporting that such cross-gender behavior has always been there. Notwithstanding such
observations, only a small number of these children will continue to meet diagnostic criteria
for GID in adolescence and adulthood. (DSM-IV-TR, 2000).
Children typically reveal their preferences and gender dysphoria through behaviors,
rather than words. Although their verbalizations should be taken into account, behaviors
and attitudes are of greater importance for the diagnostic process (Ramsey, 1998). The
transsexual boy is frequently the family’s youngest child, and the only one of the siblings
showing precocious feminine behavior. He presents stereotyped feminine activities and the
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compulsive need to participate in feminine pastimes and play (Breton, 1985). Dolls and
playing “house” are habitually the favorite games of transsexual boys, avoiding vigorous
male games and activities. The acts and gestures of male transsexuals are indubitably
feminine and clearly against the cultural stereotypes for his gender, turning these children
into favorite figures of fun and rejection by their peers. Female transsexual girls, up to their
adolescence, are usually less rejected and victimized by their peers (Vieira, 1996).
The transsexual boy, just like his adult counterpart, fully identifies with the female
role. His typically feminine behavior, attitudes and fantasies are observed in same age girls;
he also openly expresses the wish for his body to change into a female one (Stoller, 1987).
Three quarters of the boys who cross-gender, begin this behavior before the age of
four years, which is the time to play with dolls. Cross dressing usually begins around two
years of age, and it is not concomitant with sexual arousal.
Boys use their mother’s and sister’s clothing. Their vocabulary, posturing, gestures
and attitudes are feminine. They urinate sitting, play dolls with girls and make themselves
acceptable to them as peers. They devaluate their penis, never, however, denying their
masculine anatomy, but wishing to be, and thinking of themselves as, girls.
The transsexual girl is, at birth, naturally classified as a girl. Her parents are certain
of her gender, and in no way lead her to believe that she is of male gender (Stoller, 1985).
Nevertheless, this little girl, upon reaching the age of three or four years, if not before,
starts to show male behaviors and interests. The development of her gender identity
towards the male type progresses in such a way, that around her seventh/eighth year she
totally identifies with the male gender.
As children ingress into primary school, and as they acquire feelings of security,
they will share with others their sense of gender inconsonance. If on, the other hand, they
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become insecure they will hide their feelings and retract. Some boys even refuse to go to
school because of the negative, stereotyped pressures they suffer. Such serious difficulties
in school relationships tend to worsen at around the age of seven/eight years. According to
Vieira (1996), certain children, especially girls, manifest no psychopathology; others,
however, may show signs of serious disturbances, such as phobias (more often school
phobia) or recurrent nightmares.
The parents of children, up to the age of two years, do not seem to be worried by
such behaviors and attitudes (cross-gender); problems start to loom when the child faces
with social reality, outside of the family. Faure-Oppenheimer (1980) points out that it, in
such cases, it is usually family friends who suggest that the child be clinically assessed.
Families do not usually worry, considering such occurrences as a passing phase. The
mothers of transsexual boys usually appreciate them as normal, sensitive and amusing
children, but with the passing of time parents cease to consider their child’s behavior as
normal and seek help. According to the DSM-IV-TR (2000), children are usually referred
to clinics at around the age of entering primary school, as parents start to worry with a
“phase” that does not seem to pass.
Again according to Ramsey (1998), children are, day after day, confronted with
behaviors and attitudes disparate from their inner being. Although not yet aware of the
complexities of human reproductive and sexual behavior, these children are nevertheless
aware that the specific and stereotyped attitudes of those that surround them are in some
way out of step with their own. In children who are truly transsexual, the need to be truly
themselves will continue to emerge as they grow. According to the DSM-IV-TR (2000),
with the passing of time, and confronted with parental intervention and peer reaction, the
majority of these children will end up showing less obvious forms of gender-crossed
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behavior. However, Stoller (1987) thinks that such childhoods are lived with loneliness and
isolation.
Social permissiveness regarding adolescents offers transsexuals the opportunity to
dress in an androgynous fashion. Notwithstanding, the years of puberty are particularly
frustrating for the transsexual, faced with the physical maturation that comes at this time
(Ramsey, 1998).
In a boy, the feeling of being a girl can be hidden for a time, restricted by his own
dissatisfaction, but tempered by limited admiration for the female condition; it is also
during adolescence that this conflict emerges all the stronger. The feeling of not being like
others, the dysphoria and the negative feelings grow during this phase of bodily changes,
typical of puberty (Stoller, 1987).
The hormonal changes which trigger so much insecurity in non-transsexual
adolescents are even more disconcerting for the transsexual, as he/she watches the
unfolding of the undesired secondary sexual characteristics of his/her biological gender.
Adolescence forces the transsexual to face his/her physical reality and it is during this phase
that due to such anguishing experiences, abandoning school becomes more frequent, with
consequent isolation and social inadaptation.
When hormonal and anatomical changes emerge, depressive symptoms become a
regular feature of life. Depression does also affect the transsexual child, but it is graver,
more frequent and of longer duration in adolescents. Bouts of depression and self-doubt
reach tragic proportions in a transsexual adolescent, where confusion and anger can lead to
violent demonstration, alcohol and drug abuse. It is also at this stage that suicidal ideation
gains shape. The young transsexual, beyond struggling against the insecurities typical of
this phase, has also to fight against a body he/she cannot accept (Ramsey, 1998).
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The male transsexual does not value his penis, masturbates as little as possible and
when doing so fantasizes the possession of a vagina. The adolescent feels attracted to virile
men but dislikes being treated as a homosexual, because he considers himself to be a
woman and therefore such attraction is natural (Vieira, 1996). The female transsexual hates
her menstrual periods and is embarrassed by her breasts, does not like them caressed,
neither her vulva, and may even avoid undressing completely.
Many adolescent transsexuals experiment with homosexuality, with the aim of
verifying whether, or not they are homosexual; others take the risk of making
heterosexuality function for them, or, on the contrary avoid such contacts, thus abstaining
from expressing themselves sexually with either men or women (Ramsey, 1998).
“The male transsexual starts to go out with men and maintaining sexual relations.
Notwithstanding, he will never allow the partner to touch or look upon his genitals, which
for him are shameful; he defines as normal all the men who abstain from trying to do so. If
a man manifests particular interest in his genitalia, he will consider him to be homosexual,
and because his own gender identity is established by the normality of his male partner, the
male transsexual rejects all such intercourse” (Stoller, 1987).
The misunderstanding perpetrated by prejudiced people leads to an atmosphere of
shame and loneliness for the adolescent, whilst obtaining surgical transformation will lead
to more energy and perseverance in facing obstacles (Vieira, 1996).
Female transexuality usually encounters less ostracism due to cross-gender interests
and at least, until adolescence, there is less peer rejection (DSM-IV-TR, 2000). As such the
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psyche is less deviant when compared to that of the male transsexual, which presupposes
better adaptation in the different areas of life.
According to DSM-IV-TR (2000), at the end of adolescence, or at the beginning of
adulthood, three quarters of the boys with a past history of GID, will reveal either homo or
bisexual orientation, and without concomitant GID. The majority of the remaining quarter
reports heterosexual orientation, again minus concomitant GID. The corresponding
proportions for girls are unknown. Some adolescents may develop clearer cross-gender
identification and seek sex-reassignment surgery, or may continue to evolve within a
framework of chronic gender dysphoria or gender confusion.
Ramsey (1998) considers that during adulthood there are three pathways which
transsexuals usually adopt, namely:
i. Sacrifice their true feelings in the effort of becoming a “real” biological
man or woman;
ii. Drown their problems in alcohol or other conscience-altering substances;
iii. Initiate psychotherapy, which may result in the understanding of the
source of their gender confusion. Some therein discover their transsexual
condition and begin the process towards gender reassignment surgery.
According to the DSM-IV (1994), some men take self prescribed hormonal therapy
and may, in some cases, carry out their own castration or penectomy. Others, especially
those living in the urban centers go into prostitution, which places them at high risk of
becoming infected with the Human Immunodeficiency Virus (HIV). Some men have a
history of fetishist transvestism, as well as of other paraphilias.
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In accordance with the DSM-IV-TR (2000) there are two types of evolution towards
the development of GID in adult men:
i. Continuation of the disturbance with onset in childhood or at the start of
adolescence. These individuals usually seek clinical help in late adolescence
or adulthood.
ii. The more obvious signs of crossed gender identity have a late onset and
are usually accompanied, either at the start of or in mid adulthood, by
fetishistic transvestism.
The late onset group may oscillate as to the degree of cross gender identification,
more ambivalent towards sex reassignment surgery, more susceptible to attraction to
females, and less likely to become satisfied with sex reassignment surgery. Men with GID
who are attracted to men tend to have sought help in adolescence, or at the start of
adulthood, and have a long history of gender dysphoria. By contrast, those that are attracted
to women, or to both men and women, tend to present much late, and usually have a long
history of fetishist transvestism. If GID is present in adulthood it tends to typically develop
into a course of chronic evolution, but there are references in the literature to cases of
spontaneous remission (DSM-IV-TR, 2000).
Regarding the most characteristic traits of transsexuality, in a most interesting
review Sorensen and Hertford (1980), mark the distinct features of male and female
transsexuality, schematizing the phenomenology in the following way:
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Phenomenology of Male Transsexuality
Evolution
- Begins in first infancy
- Wears feminine garments in childhood, often very
early
- Female - Exaggerates the female role, favoring
role caricatures of the female ideal
Female Role
- Creates a cult of an idyllic and hypersensitive
world
- Desires to be a submissive and passive woman
- Father remembered as a distant and indifferent
figure
- Genital sexuality very often plays a minor role
Sexuality
- Relationships with men are not considered as
homosexual
- Frequent dysphoric reactions (depressive,
immature and hysterical-type
- Caricatured and stereotyped mental functioning,
with little flexibility
Psyche
- Immature and masochist tendencies
- Artemic and immature personality
- Absence of exhibitionistic and fetishistic traits, ego
centered, with complicated human relationships
- Mnesic distortions, with the exclusion of previous
masculine traits
Social life
- Social integration frequently deficient
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Phenomenology of Female Transsexuality
Evolution
- Begins in first infancy
- Frequently wears masculine garments, before puberty
- Frequent “Tom-Boy” behavior in adolescence
- Protective attitude towards the mother
- Dissociation from the father, although imitating him
Feminine Role
- The adopted gender role is a caricature and
stereotyped, although to a lesser extent than in male
transsexuals
- Tries to be domineering and protective towards
females
- Very frequent involvement in homosexual activity
- Greater similitude with homosexuality than in the
case of male transsexuality
- Desire to be dominant and active in sexual intercourse
- During the sexual act avoids the partner’s contact
Sexuality
with her genitals
- When there is genital contact this is only allowed as if
the clitoris were a penis
- During homosexual intercourse there is no role
exchange, as is customary in usual homosexual relation
- Significantly low libido
- Tendency for impulsive acts (which reflects upon, for
example, on criminality and alcoholism)
Psyche
- Tendency for openly aggressive discharges
- Depressive tendencies
- Less psychic disturbances than in male transsexuals
- Impulsive character with sociopathic tendency
Social Life
- Often social integration is better than in the case of
male transsexuals
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Classification of Transexualism
Stoller (1982) categorizes primary and secondary transexualism only in the case of
male transexuality, in the belief that female transsexuals should not be so categorizes
because when these women are very masculine, they rather represent the extreme end of a
continuum of masculinised homosexuality.
Stoller (1993) classifies transexualism in the following way:
i. Masculine Primary Transexualism. Anatomically and physiologically normal
men, with feminine appearance. Whatever their age, in their everyday behavior
they are undistinguishable from girls and women, considered as feminine by
their social group, whatever their age: onset at the end of childhood, adolescence,
young adulthood, middle-age or senescence. Their present a history of
femininity since early childhood, without episodes of stereotyped masculine
behavior, or attitudes, or even transitory. They are clearly aware of being
biological males, but from early age have a core conviction of being a female,
making all possible efforts to transform their male body into a feminine one.
They have no sexual pleasure whatsoever when cross-dressing, do not consider
themselves as homosexuals, and reject sexual interactions with clearly
homosexual men.
ii. Masculine Secondary Transsexual. Cross-gender behavior does not emerge in
early infancy, as in the case of primary transexuality, and is marked by episodes
of common masculine behaviors. Except in rare exceptions, pleasure is derived
from their male genitals. There are four patterns that precede the coming-out of
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their transexuality, and as such their requirement of gender reassignment
surgery:
Progression, throughout the years, of feeling to be homosexual, with
inclination to be feminine, or effeminate, and at a certain time the feeling that it
would be advantageous to be a woman.
Transvestite progression, where after a long or short period of wearing
feminine garments to obtain sexual gratification, they become aware that crossdressing is not so much sexual pleasure, but rather because it makes them feel
like women.
Desire for gender reassignment surgery after a period of homosexual
engagement, more or less expressed in an exclusive fashion
Without heterosexual, homosexual or perverse, extensive engagement, but,
on the contrary, a very low sexual need in a man, whose gender behavior has not
been manifestly eccentric
iii. Feminine Transsexuality. A biologically normal woman, recognized as such,
and so identified at birth, but who, nevertheless, has male behavior and fantasies
since early infancy. This masculinity is uninterrupted throughout her life course.
Comparable to the primary male transsexual, as a child she is often taken for a
boy, plays only with boys, takes on a male name and wishes to become a man.
During adolescence lives permanently as a man, exercises a typically male
profession, feels sexually attracted only to women designated by herself as
extremely feminine, and tries to transform her body into a masculine one.
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Silveira Nunes (1987) classifies transexuality into five categories: primary
transexualism,
secondary
transexualism,
symptomatic
transexualism,
atypical
transexualism and pseudo-transexualism.
i. Primary Transexualism. Like Stoller, primary transexualism refers to those
individuals who precociously develop a gender identity incongruent with
their anatomical gender. There is an early attempt to adapt to that precocious
discordance and later in life, during adolescence or in adulthood, try to seek
gender reassignment surgery and alteration of their civil status. Sorensen and
Hertford’s (1980) outline of the phenomenology of masculine and feminine
transexuality conforms to that which this author classified as primary
transexualism.
ii. Secondary Transexualism. This is a late onset transexualism and as a
general rule evolving, wherein its evolution may start, as in the most
frequent cases, from transvestism or homosexuality.
iii. Symptomatic Transexuality. Here assessment is usually a more simple
procedure as it is based on three distinct situations: schizophrenia, where the
delusion of gender identity transformation is accompanied by delusional
synaesthesia of bodily changes; in certain situations of depression, such as
the masked depressions of middle age; and in “transsexual crises”, which
emerge in certain situations of stress in individuals with varying degrees of
gender identification vulnerability.
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iv. Atypical Transexualism. Unifies situations such as “fluctuating gender
ambiguities such as borderline transsexuals or marginal transvestites, where
it is felt that identity is only one of the issues, but due to the gravity and
unfound solution in the various adopted strategies, change of identity ends
up as appearing as the possible solution”.
v. Pseudo-Transexualism. “This is the place found for factitious desire for
transexualism”, as in the case of certain transvestite homosexual prostitutes,
or in cases of genital dismorphobia.
Landén et al (1998) classify transexualism as primary and secondary.
i. Primary Transexualism. Individuals with aversion for their own gender
(biological) and with the strong conviction of belonging to the opposite sex.
Tomboy – biological female who presents characteristics of male gender role
(McDermid et al, 1998), or effeminate behavior, in accordance with being
either biologically male or female, present since early infancy. Crossdressing is not associated with sexual arousal and there is a sexual attraction
for members of their own biological gender. There are no fluctuations in the
symptoms of gender dysphoria.
ii. Secondary Transexualism. There is a strong conviction of belonging to the
opposite sex, fetishist transvestite behaviors or a non homosexual orientation
(sexual relations are heterosexual o bisexual, in accordance with the
biological gender).
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Carroll (2000) classifies transexualism only as primary, subdividing it into three
categories: feminine gender dysphoria, male gender dysphoria – type androphilia; and male
gender dysphoria – type selfgynophilia.
i. Feminine Gender Dysphoria. Women identified as masculine in their
appearance and behavior, from early infancy, around the age of three years,
or even earlier. Since children they have shown a preference for masculine
games and sports, rather than for dolls, and prefer the company of boys to
that of girls. They hate to wear stereotyped female clothes, and usually voice
that they will be men when they grow up. Adolescence implies great
emotional torment, with great anguish experienced with the bodily changes
associated to puberty. They feel sexually attracted to women. Whilst
adolescents, or young adults, there is an attempt to solve their problems
investing in female homosexuality, which, however is experienced as
unpleasant as they cannot abide being thought of as women, neither that
other women should feel attraction for them as females. They may be able to
develop a relationship with a woman, providing that she feels attracted by
their masculinity and their wish to be men. In adulthood, they consider the
option of hormonal treatment and gender reassignment surgery.
ii. Male Gender Dysphoria – Type Androphilia. In classical typology of
transexualism, this is known as homosexual type. These are boys considered
since birth as effeminate, pretty and delicate. In infancy their show
preference for feminine play, avoiding competitive sports and typically male
activities. They like wearing feminine garments, but this is never associated
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to sexual pleasure. They have a particularly strong and close relationship
with the mother, who may encourage effeminate behavior. Since the onset of
sexual awareness, during infancy, or puberty, they feel sexually attracted to
males. Homosexual relationships are frequent in adolescence. They may
become involved in prostitution, or take on Drag Queen behaviors. There is
a preference for heterosexual partners, whom they consider to be attracted by
their own femininity, and which will confirm their own self-assessment of
being female.
iii. Male Gender Dysphoria – Type Autogynephilia. Also designated as
homosexual transsexualism or transvestism. Previously these individuals
would be known as transvestites or secondary transsexuals, and would not be
considered appropriate for gender reassignment surgery. Autogynephilia
refers to the experience of sexual arousal triggered by the man’s fantasies of
himself as a woman. For many of those who meet DSM-IV (1994)
diagnostic criteria for fetishist transvestism, autogynephilia is a prominent
sexual activity. They are not considered to be effeminate boys. Before
adolescence, they begin to wear stereotyped female clothing, usually
belonging to their mother or sisters, and refer to the cross-dressing
experience as pleasant and comfortable, but not erotic. With the emergence
of puberty they feel sexually attracted to girls and women; however, sexual
arousal increases if imagining themselves with a female body, or being taken
for women. To repress female identity they force themselves into
stereotyped male roles, but with the passing of time the fantasies of being
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women become stronger. Often, they manifest symptoms of depression
and/or substance abuse, as the outcome of inner conflicts of gender identity.
Sometimes the desire to become a woman is resisted, in the fear of losing
wife, children or job. When they enter treatment they are usually desperate
for a very rapid change.
Sociological Aspects
Money and Ehrhardt (1972), eloquently contrasted “identity” and “role”: “Gender
identity is the private experience of the gender role, and gender role is the public expression
of gender identity”. For Griggs (1999), when differentiated gender is maintained in
opposition to differentiated sex, this will imply suffering, which is not always apparent to
others, such as family and friends. For a while, the public expression of gender may emerge
without worry and difficulties, even though it is in contrast to the private expression of the
same.
Transsexualism is the breaking with traditional gender roles. In our society there are
two “classical” roles: that of man and that of woman, which are clearly tied to the notion of
biological sex. It is expected that a person should have behaviors and attitudes in
accordance with the given biological body (ILGA, 2001). Various authors suggest that the
pressure to conform to conventional roles results in low self-esteem and hate towards
oneself, especially when that pressure is combined with aversive therapy (Mallon &
DeCrescenzo, 2006).
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To assume transsexuality in a prejudiced society is most painful (Ekins & King,
1997). It is undisputable and undeniable that the transsexual suffers because of rejection
and the insensitivity of others to the problem.
“Oh my God, how we are shamed. She went to the policewoman’s desk and said she was a
woman. The officer answered: “What? You are a man.” The policewoman: “You are not a
woman”. And that confusion persisted until I was freed.” (Testimonial of a male
transsexual, detained by the police for just wearing female garments)in 263
Humankind tends to drop prejudices after acquiring scientific knowledge of an issue.
Sociology shows the relativity, culture dependent, of what is normal and abnormal. Such
relativity is also applicable to transsexualism. There are nations where its occurrence and
treatment are far more obvious, and its existence far better socially tolerated. Nevertheless,
there are also societies where transsexuals are rejected, be it because of lack of knowledge
of the problem, or because their claims are considered to be threatening to the social order
(Vieira, 1996).
Transsexuals often face discrimination and rejection by society, their families,
friends, fellow workers, health care givers and their own religion (Bullough & Weinberg,
1988; Gagne & Tewksbury, 1996; Gagne et al., 1997; Bockting, Robinson & Rosser, 1998;
Kammerer et al., 1999; Namaste, 1999; Bockting & Cesaretti, 2001). This stigmatization is
worsened for transsexuals who also have to face other sources of stigma and discrimination,
such as those related to their race, sexual orientation (being a homosexual or bisexual
transsexual) or of gender (being a transsexual and a woman) (Mathy, 2001; Masequesmay,
2003; Gutierrez, 2004).
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The transsexual has to face enormous sacrifices, such as the lack of money,
suffering, loss of employment, family conflicts and conflicts with his social milieu, in order
to be able to live with the identity he/she feels to be the true one, after a long therapeutic
process. The data from convenience samples of transsexuals in the United States of
America, show high levels of verbal abuse, physical violence, and discrimination in
housing and employment (Clements et al. 1999; Lombardi, Wilchins, Priesing & Malouf,
2001; Reback, Simon, Bemis & Gatson, 2001; Keatley, 2003; Xavier et al., 2005), such
data conclusively show that transsexuals are a population in risk (D’Augelli and Slater,
2006).
The transsexual cannot enjoy the freedom which is his/her birthright;
the
transsexual feels like a prisoner, as Ayalain 263 (1951) refers in Historia de la Liberdade,
(p12-13):
“In effect, human societies do not possess a unique and immutable structure; rather, thy
organize themselves into very different types and, within themselves, are subjected to a
constant evolution, being this the result of man’s free will, who act in their midst, forming
history; therefore, the saying, in that sense, History is the work and the witness of
Freedom”.
Justice is above all, and before anything else, the freedom that implies respect for
each individual personality (Teixeirain
263
, 1986; in Reflexões sobre a justiça, p.4).
According to Vieira (1996), individual freedom cannot suppress or eliminate order, but
power cannot be imposed irrationally, with the only purpose of obtaining obedience. The
transsexual breaks no rules for wanting to adjust the body to the soul and to the mind.
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According to Currah, Minter and Green (2000), continuous abuse and discrimination in the
workplace are increasingly coming to the notice of the courts.
According to Green (2007), in various countries, fundamental protections have been
decreed either through judicial decisions, or statutes to minimize the negative consequences
of transsexualism. The majority of States in the U.S.A. provide an altered birth certificate
so that the transsexual may enjoy the full juridical states of the new gender. This allows for
marriage in 49 of the 50 states that prohibit marriage between individuals of the same
gender. Some countries maintain the refusal to change the birth certificate, including, until
recently some European countries. However a ruling from the European Court demanded
that the United Kingdom allow for change of the birth certificate after two years of living as
a member of the opposite sex. Such a measure will allow for marriage with a person of the
same birth gender. The protection that some countries afford to transsexuals, under the
sexual discrimination statutes, and which allows them to be issued with a document that
validates the undergoing process of gender reattribution, during the real-life test. In the
U.S.A., many States and the Federal Government have recently emitted specific rules for
protection in the workplace. Unfortunately the same cannot be said for Portugal, where
notwithstanding the transsexual is the bearer of a clinical declaration stating the ongoing
process of gender change, discrimination in the workplace is too real.
Family Adaptation
Parental support may be a protection against psychological distress (Goldfried &
Bell, 2003). All too often, the rejection of the transsexual begins with the family, parents
and siblings (Vieira, 1996). The relationship with one, or both parents, may be seriously
injured (DSM-IV, 1994). The majority of parents react negatively to the transsexual
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condition of his/her child (Grossman et al, 2005). Some parents are abusive, with some
studies reporting that suicide levels are more frequently associated with parental verbal, or
physical, abuse. Without parental support, young transsexuals are more likely to abandon
school, run-away, become homeless; there is also an increase in the likelihood of substance
abuse and sexual abuse (Ryan, 2003).
According to Ramsey (1998), the more secure the family members feel regarding
their own sexuality and gender identity, the better equipped they are to deal with the
transsexual with empathy. Also, without doubt, the healthier a family is the healthier and
better adapted its transsexual member.
The write Luis Mott refers that in his own childhood, around the age of six/seven
years, he tried to rebel against the imposition upon him of masculine stereotypes.
Notwithstanding his desires, he refers that (in Lesbianism in Brazil, 1987)in 263:
“Repression in the family, in school and in the neighborhood was stronger than my childish
will; today I interpret my entering the seminary, as an unconscious strategy found to enable
me to realize that desire, if not of changing sex (transsexualism), at least of transvestism,
and if not using lay clothes, at least through a priest’s gown. And I was vain when exactly
choosing the religious order which had the most beautiful gown. Dominicans, with
everything white, just like a bridal gown! I am not a woman because an accident of nature
did not permit me to be so, and I was cowardly forced by society to conform to social roles
which identify my biological sex. If not, who knows, I could be in competition with Roberta
Close.”
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It is not the fact of wishing to have been born with the other gender that determines
a person’s transsexualism. Without doubt other factors influence this condition, as
previously explained. According to Vieira (1986), through the above statement it can be
stated that it is not wrong, for the family to try to change the child, during infancy,
primarily for two reasons:
i. The family is not aware what the child is going through;
ii. When confirming that the child’s attitudes are in opposition to those
expected, the family should seek specialized professional care, so as to
clarify the issues.
Various authors have developed model of family adaptation, in stages (Emerson &
Rosenfeld, 1996; Ellis & Eriksen, 2002; Lev, 2004), and a basis for the internalization of
the process by stages of grief, as described by Kubler-Ross (1969). In their majority,
parents need to go through a period of grieving for the loss of their little boy or girl. Only
after going through such a process can they accept to receive into their lives the new son, or
daughter. Often the family goes through a period of rejection, in the hope that their child
will change, mature in another direction, or fall in love with someone who will “set her/him
in the good path”. Only when families fully understand that the transsexual is not rejecting
them, but his/her own biological sex, can family ties be re-established (Ramsey, 1998).
Many transsexuals lose their friends and family members due to their
incomprehension and rejection. All these negative experiences trigger additional difficulties
for the transsexual patient during a period in life inevitably anxiogenic and traumatic (The
Looking Glass Society, 1996).
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For Ramsey (1998), the family, namely the parents, whilst trying to understand the
reasons for their child’s transsexualism, tend to blame themselves, the other parent or the
family tree. Many parents adopt strategies so as to force their child into normality. When
the child does not back down, as expected, commonly the parents project their feelings of
anger and anguish onto one another. Such recriminations often lead to marital conflict, and,
in some cases, even to divorce. Facing such discord, separation or divorce, the child often
feels guilty, believing that had they been a “good boy” or a “good girl”, problems would
not have arisen and the family would have continued united. In some cases, even when the
parents come to understand that neither of them is to blame, they remain incapable of
finding the way to reconciliation.
Again, according to the same author, usually the mother adapts and accepts the
transsexual child, independently of its gender, more easily than the father. The mother is a
more probable confidant for the transsexual, who tend to be more supportive than fathers
(Grossman et al., 2005; Garofalo et al, 2006). The father, although ending up by accepting,
finds it clearly more difficult to do so, especially when the transsexual is a biological male.
Even though the typical father enters into conflict, when his daughter wishes to become a
man, final acceptance occurs more easily .The father has the tendency to cling to technical
and historical details, which enable him to construct his own pseudo-academic theory. The
mother, on the other hand, is more deeply affected by emotional and social variables. When
the parents are called to the Clinic, the likelihood is for the father to appear later;
sometimes even after the whole family has united their efforts and their process of
acceptance and support for the transsexual already initiated. The siblings of transsexuals
also live through feelings of guilt, but less intensely so than their parents. Whilst parents
rarely put into question their own sexuality and sexual orientation, siblings are confronted
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by fears and worries. It is precisely in the course of the first adolescent years that siblings
tend to experience greater difficulties. In this stage, adolescents, who often attend school
and live with the parents, even though they may accept their transsexual sibling, they will
invariably suffer social tensions at school, when colleagues learn of the situation. As a rule,
siblings who are young adults, no longer living at home, tend to better cope with a the
sibling’s transsexualism.
An important source of evidence, in the field of family issues, portrays the
difference in gender. According to Kockott and Fahrner (1987), female transsexuals more
often display stronger links with parents and siblings, and also tend to have more stable
partnerships. Thus, male and female transsexuals differentiate regarding social and sexual
behavior, independently of having, or not, submitted to gender reassignment surgery. When
first seeking treatment, female transsexuals are already better socially integrated.
Academic and Professional Adaptation
Restrictions are a constant in the day-to-day school life of a transsexual, thereby
implying an injustice, which will brand him/her for life (Vieira, 1996).
According to the DSM-IV-TR (2000), many individuals with GID develop social
isolation. Isolation and ostracism contribute to low self-esteem and may lead to aversion for
school and eventual dropping-out. Ostracism and being made fun of are frequent
consequences, encountered by GID boys, who very often also show typically effeminate
mannerisms and language patterns. GID may be so enclosing, that the individual’s psychic
life turns upon activities which diminish gender distress. Very often they are preoccupied
with appearance, especially when starting to live in the opposite gender role.
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For the transsexual, the simple fact of having to change clothes, let alone take a
shower, in the common dressing-room for a gymnastic class, can turn into a painful and
distressing experience. The depreciating comments, the jokes and the comparing of genitals,
all common in adolescence, are indubitably aversive for the transsexual. So as to avoid the
unpleasantness felt in gymnastic classes, or in other gender stereotyped activities, it is
frequent for transsexuals to refuse to go to classes. Thus, schooling may represent a
turbulent pathway, beset by many difficulties.
In accordance with a study carried out by Sausa (2005), 96% of participants reveal
to have been subjected to verbal harassment, 83% were physically molested, and 73%
referred feelings of insecurity, which led to abandoning school and giving up all hope of
academic training. These young people report difficulties predominantly with teachers, and
some related to the use of equipments such as stereotyped toilets and dressing rooms.
Other studies confirm the frequent harassment and verbal aggression frequent lead to grave
academic difficulties for the young transsexual and frequent subsequent dropping-out from
school (Rosenberg, 2003; Grossman & D'Augelli, 2006).
The pre-surgery social-professional integration of the transsexual is not easy to
accomplish. Obtaining a job is usually very difficult. The majority of transsexuals finds that
the professional difficulties encountered are either diminished, or vanish, from the time,
after gender reassignment surgery, that civil status registry is changed so that physical
appearance harmonizes with gender registered. However, in the years that preceded this
final process, the clash between physical appearance and civil identity emphasized
prejudices, driving the transsexual into painful situations and ostracism.
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A male transsexual, who obtained excellent high school grades, describes his
attempts to find a job:
“I am working at home, or better put, I look after the house. All attempts at finding outside
work, just like any other person, that is to lead a normal life, were failures, all because I am
a transsexual. People say they want to help me, but instead take advantage of the situation,
exploiting us by paying less. An event that marked me very deeply, was that when looking
for work, for the first time, I had to give my name as it figures in my Identity Card, and fill
in a form; it was for a typing test and if approved I would get work as a typist. There was a
great fracas and I was very embarrassed, as people would come to spy on me as though I
were a freak; nevertheless I completed the test and did well. The person responsible for
correcting the tests told me that so far I had been the best candidate. After a few days I tried
to find out the results and found that someone else had got the job. What saddened me most
was that the job went to someone less qualified than me. The person in charge tried to
justify herself, but I had already understood it all”.in 263
According to Vieira (1996), due to the prejudice encountered, the great majority of
transsexuals attach great importance to the hormonal and surgical treatments, as well as to
the name and gender correction in the Civil Registry, to enable them to obtain an acceptable
working life.
At professional level, female transsexuals are much better integrated than their male
counterparts, which predicts that they are better adjusted (Millon, 1983). For Vieira (1996)
this better equilibrium is afforded by the respect that female transsexuals command, and
their own assertion. Besides, it is a long established tradition for women to wear garments
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previously considered as masculine. Such behavior affords more freedom of movement,
especially in the case of active women and therefore it is not a shocking practice.
The presence of a transsexual in a working team seems to provoke relationship
problems. Therefore, to avoid problems, some transsexuals inform their boss, staff director
and some colleagues, of their problem. Some, who manage to procure a job, on the other
hand, refuse to disclose their true identity, in attempt to safeguard their work post. The
reasons that will allow the transsexual to, or not, reveal his problem are extremely complex
and depend, amongst other factors, on his intelligence level, his family conflicts, his
professional training and learning (Vieira, 1996). According to the same author, the
misunderstanding due to lack of knowledge of the problem and the fear of scandal are the
main difficulties encountered by transsexuals, barring the way of their social and
professional integration.
The professional integration of a transsexual person should be permitted in
accordance with their real aptitudes, physical and psychological; it should not be done
according to an endurance test against prejudices. The transsexual wishes to be, and should
be respected for the person that he/she is.
Religious Issues
For some transsexuals the religious issue is both important and disturbing. In some
cultures, transsexuals grew up with the warning that homosexuality is a mortal sin; some
believe that cross-dressing is equally a sin for which they will be punished. Such
individuals believe that there are jeopardizing the future of their soul, and are facing not
just the loss of family and friends, but also the divine final judgment, which can lead to the
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aniquilation of the spirit. To confront, explore and defy such beliefs requires an incredible
energy and personal faith (Ramsey, 1998).
Sex is a fundamental attribute of human nature; nevertheless, although there are
religious writings in great abundance, the majority attribute little importance to the factors
appertaining to it (Vieira, 1996).
In Judaism, men and women are exclusively defined by their external genitalia;
there is no acknowledgement of the internal sexual organs, nor of the chromossomatic
characteristics – neither, a fortiori, of psychological factors (Pettiti, 1992).
Dwelling upon the validity of transsexualism, religious Judaism advises that it
should be treated by psychotherapy and even adequate hormonal therapy, but prohibits all
recourse to surgical means. Judaic religious codes consider as an absolute canonical
impossibility the masculinisation of a female; it also formally rejects the feminization of a
man by surgical means. Coitus between a normal man and a surgically feminized man
(castrated) is considered to be the crime of sodomy (Erlichin 263 in Les mutilations sexuelles).
Islam stigmatizes not just homosexuality, but also male and female transvestism.
Such a position, according to Erlich, is in synchrony with other religions, thus legitimizing
gender reassignment surgeries in Muslim countries. Sexual anomaly of genetic origin is
clearly recognized in divers religious texts that refer to hermaphroditism. The Koran
contains various verses damming those that adopt attitudes, or behaviors, contrary to their
nature (Vieira, 1996).
The doctrine of Spirits, or Spiritualism, in accordance with Kardecin
263
(1981),
presents as a principle the relationship of the material world with the spirits or beings from
the unseen world. In Humankind there exist an intelligence principle, designated as the soul,
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or the spirit, independent of matter, and which provides moral sense and the faculty for
thinking.
For the doctrine of Spiritualism, the union of the body to the soul, begins at
conception, but is only complete at birth. As the hour of birth approaches, all ideas are
extinguished, as well as all memories of the past, which ceases to feature in human
conscience, the moment it is birthed. After incarnation the spirit cannot lament a choice of
which it has no conscience. It can, however, consider his a heavy load, for which it has no
strength. The real lodge of gender is not in the physical frame, but in the spiritual entity.
Mental gender, in its impulses and manifestations, transcends any limitations imposed on
the way of expression (Vieira, 1996).
According to Vieira (1996), Spiritualism claims various possible explanations for
the origins of transsexualism: the soul’s past strength, where it would still be fortified by
past emotions and experiences, thus influencing the psychic life of the new body that
supports sexual organs of opposite tendencies; of individuals situated on the masculine axis
rehearsing the feminine side of a future reincarnation, already outlined by the transitional
effect of the Law that seeks psychological equilibrium.
Within Catholicism, there is no explicit position on the moral issues posed by
transsexualism. In a moralist perspective, the Church invites the believer to recognize his
sexual condition as part of the gift of the Creator, and which make up his self (Vieira, 1996).
“The Church is restrictive, because of the belief that the problems of personality
integration should be solved by psychotherapeutic treatments” (Pe. Márcio Fabriin 263, in
Igreja só aprova em hermafrodita).
The history of each transsexual varies, but many take the fate of their souls seriously.
The majority believes that through surgery, a congenital error is corrected, and that God
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will understand, even when others don’t. Many states being unable to find in the Scriptures
a passage directly mentioning the issue of transsexualism. Often transsexuals direct their
anger towards God, believing themselves to be victims of an injustice. Many doubts arise,
such as why should a compassionate God allow them to suffer so, and how and why should
God permit that a person’s biological gender should be in contradiction with the emotional
and psychological being (Ramsey, 1998).
Ramsey (1998) proposes the following orientations for dealing with religious issues
in transsexualism:
i. Do not defy or criticize the patient’s beliefs;
ii. Stimulate the seeking of religious counseling, within their own
congregation, and with a qualified counselor. There are understanding,
sensitive, clerics, who are also willing to listen;
iii. Encourage prayer, meditation and other forms of participating in
religious practices;
iv. Encourage them to speak to other transsexuals in the congregation;
v. Help them to reflect on their own issues, never interfering in decisions
taken. The aim is not to persuade someone; the decision is the individual’s
right.
Relative to the religious conflict subjacent in some transsexuals, Kim Elizabeth
Stuartin 158, in her 1983 book, The Uninvited Dilemma, reflects in the following way:
“Many of those who oppose gender consonance raise the question of religion and proffer
statements such as “God made you the way you are, and you have no right to change that”.
But where are their protests when artificial limbs, or heart valves, are given to people with
- 106 such deficiencies? In accordance with such religious logic, people should not take
advantage of the advances of modern medicine because “God made those people in the way
that they are. Where are the protests when diabetics are injected with animal-derived
insulin? Where are the protest when minute babies… are operated to solve congenital or
genetic deficiencies? Where is the clamoring… when Siamese twins are surgically parted,
so they (or at least one) can live a normal life? Certainly, if God made transsexuals, that
same God must have made Siamese twins. The present implication is, obviously, that
transsexuals themselves chose to be so, whilst those with physical, or developmental,
deficiencies, be they congenital or genetical, as well as those who developed certain clinical
states, had no choice. But this makes no sense whatsoever. Nobody chooses to be a
transsexual, just as nobody chooses to be a diabetic… The only choice which can be
attributed to the transsexual is what he/she will do regarding that condition. Those who
clamor against surgical interventions in transsexuals, alleging religious motives, are the
greatest hypocrites. They claim to follow the teachings of Jesus, who preached the love of
God for thy neighbor; nevertheless they are capable of turning their back on their neighbor
and condemn him to internal hell, based on their interpretations of what is right and
wrong… It is necessary for those legislators of morality to keep their spiritual garden free
from weeds, instead of constantly throwing those same weeds into their neighbors’
garden”.iv
For Ramsay (1998), the vast majority of transsexuals manage to solve their spiritual
issues. However, according to Vieira (1996), the Catholic Church, as the congregation with
the greatest number of transsexuals, cannot continue to irrationally ignore the issue. All
those questions considered to be taboo, should be studied by all the religions, with the aim
iv
Translated by the researcher.
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of revising and modifying some positions; not to do so is to incur the risk of distancing
themselves from their brethren, and loosing them day, after day.
Studies of Transsexualism
In accordance with the themes emphasized in the present research, various studies
which consider personality, psychopathology and social adaptation, shall be reviewed.
The feeling of not being like others, dysphoria and negative self-feelings develop in
adolescence and increase with changes at puberty, leading to feelings of loneliness and
isolation. Many individuals with GID thus develop social isolation. According to DSM-IVTR (2000), the scorn and ostracism imposed by peers are very frequent in GID boys who
have clearly effeminate mannerisms and speech patterns. Another relevant aspect is the
proven impact of stigmatization, which contributes to low self-esteem and favors the
vulnerability to develop associated symptomatology. It can hardly be surprising that many
markers of psychopathology are found in the transsexual population.
Blanchard, Clemmensen and Steiner, in 1983, carried out a study on a sample of
transsexuals, with the aim of exploring the social adaptation between the psychological and
biological dimensions. As assessment instruments the authors used a thematic questionnaire
and the Minnesota Multiphasic Personality Inventory (the M.M.P.I.). The results show that
in F-M transsexuals there is better social adaptation at the level of the psychological
dimension. Nevertheless, there is also clear evidence to lack of adaptation regarding
occupying leisure time and extended family relationships (Monteiro, 2002).
F-M transsexuals are described as showing better psychological and social
adaptation, with more stable jobs and also more realistic expectations regarding the gender
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reassignment surgery (Pauly, 1974)in 134. In M-F transsexuals there is evidence for greater
frequency of histrionic personality, immaturity and suicide attempts. Consequently, the
outcomes of gender reassignment surgery are usually less satisfactory in M-F transsexuals,
in comparison with their F-M counterparts (Blanchard et al., 1985; Kuiper & Cohen –
Kettenis, 1988; Landén et al.in
134
, 1988). The greater therapeutic successes in female
transsexuals, may partially result from the fact that society accepts more easily the
spontaneity of a woman who dresses and behaves as a man, rather than a man who behaves
as a woman (Hayes and Leonard, 1983); such an observation is consistent with the
evidence of various studies that show that M-F cross gender behavior is subject to greater
social disapproval (Zucker et al, 1995; Cohen-Kettenis et al, 2003). The feminine gender
has faced less intra and inter- personal difficulties due to social attitudes. Women
confronted rejection and social opprobrium, for wearing masculine garments, many decades
ago. Presently, some masculine attitudes in women are actually appreciated, because of
their very connotation and the benefits they may garner, both at professional and family
level (Monteiro, 2002).
Ramsey (1998) refers that relationship difficulties are frequent and therefore
functioning in school, or at work, may be impaired. However, as Vieira (1996) points out,
relationships in F-M transsexuals habitually last longer, than in M-F counterparts. In
accordance with the DSM-IV (1994), GID often implies anxiety and depressive comorbidity. Other authors reinforce this propensity for anxiety, already present in infancy,
especially in the male sex (Wallien, Van Goozen & Cohen – Kettenis, 2007).
The National Institute for Mental Health estimates that, in the American population,
25% of those with GID may show psychiatric symptoms of anxiety, depression, alcohol
and drug abuse, and personality disorders (Weissman & Myers, 1978; Robins et al., 1984;
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Weissman et al., 1991)in 51. Some studies have suggested that there may be an increase of
the incidence of serious personality disorders, and other mental disturbances, amongst
clinical samples of transsexuals (Hoening, Kenna & Youd, 1970; Derogatis et al., 1978;
Dixen et al., 1984; Beatrice, 1985; Bodlund, Kullgren, Sundbom & Hojerback, 1993;
Hartmann, Becker & Rueffer-Hesse, 1997). As far as general psychopathology is concerned,
transsexuals show greater frequency of obsessive-compulsive, interpersonal sensitivity,
depressions and paranoid ideation traits (Monteiro, 2002). In clinical practice, it is common
to encounter transsexuals who manifest paranoid symptoms, and behavior and experiences
due to general cognitive difficulties, due to their internal identity conflict.
The need to attribute greater acuity to the DSM-IV Axis II diagnoses, put an end to
worrying regarding the previous isolation of GID from its subjacent personality. In GID in
adolescence and adulthood, the Axis II diagnoses are usually clear, with the Borderline
personality structure as the most frequent.
The subjacent personality structure makes up the structure that completes GID. GID
manifests personality disorders (Monteiro, 2002) v, and transsexualism does not imply a
mere reversal of stereotyped gender roles: transsexuals differ not only from nontranssexuals individuals of the same biological gender, but also from those of the opposite
sex. M-F transsexualism does not represent the inverted image of F-M transsexualism:
rather it constitutes a more extreme condition of identification with patterns of feminine
personality versus masculine. These differences seem to be universal in various countries
and regions (Herman-Jeglinska, Grabowska & Dulko, 2002).
v
An explorative and comparative study with three study groups (the experimental group – n=17 transsexuals;
the control group for biological gender – n=17 general population; control group for psychological gender –
n=17 general population.
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Breton, Frohwirt, Gorceix and Kindynisin 263, carried out a studyvi, between 1981
and 1983, with thirty transsexuals (twenty one M-F and nine F-M). Regarding the affective
dimension, frequent isolation was found: 19 of the total 30 lived alone. Amongst the nine
F-M transsexuals, two lived in marital relationships, whilst this was true for only three of
the twenty one M-F transsexuals. Regarding the results of personality tests (the MMPI and
the Rorschach) the thirty cases were divided in the following fashion: 14 sub-normal
personalities (10 of the 21 M-F transsexuals and 4 of the nine F-M); 9 neurotic personalities
presenting disorder with depressive symptoms: anxiety, emotional labiality, affective
vindication (6 cases in the M-F and 3 in the F-M transsexuals); 3 borderline personalities
(fragility, lack of affective and relationship adaptation, with 2 cases in the M-F transsexuals
and 1 in the F-M transsexuals ); 3 psychotic personalities, presenting serious disturbance of
reality appraisal with sub-delusional elements and grave affective disturbance (2 cases in
the M-F and 1 in the F-M transsexuals); 1 psychopathic personality, where the person
defines himself as a male transsexual with a female homosexuals orientation. This case was
considered as an original amongst the group studied. According to the authors the last three
groups mentioned should not be considered as true transsexuals, but as individuals with late
expression of transsexualism, wherein gender adequacy is requested at a point of much
more advanced agevii. When considering the average MMPI profile, it was seen that these
are placed within the subnormal zone regarding their anatomical sex, but in the normal
zone if their pretended gender is considered. When specifically analyzing the Mf scale
vi
Regarding age, the F-M transsexuals were between 25 and 47 years, with an average age of 25 and the M-F
transsexuals were between 20 and 62 years of age, with the average age of 36 years.
vii
Of the 21 M-F transsexuals, 7 were over 50 years of age and had lived a long time in conformity with their
anatomical gender, albeit with the permanent conviction of having cross-gender identity, which, however, did
not stop them from building a family and enjoying successful social and professional lives. Later on,
considered that their duties towards their children and society had been discharged, they desired to carry out
their dream, risking carriers and family opprobrium.
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(Masculinity-Femininity), it was shown that individual scores emerge in accordance with
the pretended gender. Regarding M-F transsexuals, there is a slight rise in the Hs
(hypochondria) scale, denoting more marked bodily preoccupations together with
relationship inhibitions. With respect to the F-M transsexuals there is a slight elevation in
the Pd (psychopathy) scale, pointing to traits characterized by aggression and hyperactivity.
Boldlund and Kullgreen (1996) carried out a study with 90 transsexuals, assessing
the areas of social, psychological and psychiatric functioning. This study showed that: F-M
transsexuals evidenced better general adaptation, namely in establishing and maintaining
relationships, and at socio-economic level, when compared with M-F transsexuals; F-M
transsexuals show greater success in various areas such as relationships, as well as work
capacities; M-F transsexuals showed greater difficulties in social adaptation and greater
prevalence of personality disturbances. Both M-F and F-M transsexuals evidence antisocial personality traits.
Cole, O’Boyle, Emory e Meyer (1997), studied 435 transsexuals, with the aim of
investigating co-morbidity with the Axis I and Axis II disturbances, in accordance with the
DSM-IV (1994). As assessment instruments the authors used a specific and detailed
interview and a personality measure (the MMPI). Only a subgroup of the transsexuals was
tested with the MMPI (93 F-M and 44 M-F, in a total of 137 transsexuals). The results
show the following data: in the M-F transsexuals there were 6 with borderline personalities,
4 with schizoid personalities, 2 with anti-social personalities and 1 with cognitive
impairment; in the F-M transsexuals the results were the following: 2 with borderline
personalities, 1 with schizoid personality and 1 with passive-aggressive personality.
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Analyses of the MMPI profiles revealed an increase in the Mf (Masculinity-Femininity)
scales and in the Pd (Psychopathy) scales. It was also evidenced that on the Mf scale, the
M-F transsexuals score in accordance with the criteria of the desired gender (feminine),
whilst the F-M transsexuals score in accordance with the criteria for both of their genders
(anatomical and desired). Coussinoux et al. (2005) reinforces the observed increase on the
Mf scale, and adds that transsexuals, who have yet to undergo gender reassignment surgery,
present a significantly increased average score on this clinical scale (regarding their
biological gender), when compared with post-operative transsexuals. These authors
conclude that absence of significant differences found between pre and post-surgery is a
surprising find, and suggest that the hormonal treatments appear to have little impact on the
process of gender identification, thus proving conformity with the self-perception of gender.
Saadeh (2004) comparing the presence of depression and of personality disturbances
after two years of group psychotherapy, pointed to the predominance of depressive
symptoms, but referred no statistically significant data regarding personality traits and
disorders. According to Breton (1985), and with the various studies in this field, it is
interesting to appreciate the organization of the personality of transsexuals, namely its
solidity, its adaptive plasticity, thus enabling the establishing a prognosis for social
integration, especially when having to decide on the adequacy of a surgical intervention as
well as civil registry change.
Research on possible change of personality profiles in this clinical population has
not been unanimous. A study by Monteiro (2002), concludes that there is greater
prevalence of personality disturbance, clinical symptoms of psychopathology, intra and
inter-personal difficulties in a group of transsexuals in the initial phase of the process of
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gender reassignment, namely during initial assessment, in comparison with transsexuals
who are in more advanced stages of the same process, namely during the real-life test and
endocrinological treatment. Such evidence suggests significant change in the various
dimensions studied, in accordance with the phases of the process of gender reassignment.
Personality factors are important indicators of prognosis that is the probable success
or lack of, of the gender reassignment surgery (Lothstein, 1982; Shone, 1984; Korlin &
Uddenberg, 1987; Bodlund, Kullgren, Sundbom & Hojerback, 1993; Meyer – Bahlburg,
1993; Tarsh & reid, 1993; Sundbom & Bodlund, 1999). Whilst the process of gender
reassignment is indubitably considered as the treatment of choice for GID, the transsexual,
after surgery, continues to be a fragile individual (Cuypere et al., 2006). The various
dimensions of psychopathology and social adaptation are also eminent and must be taken
into consideration when contemplating a process of gender reassignment. The study of
Haraldsen and Dahl (2000) suggests that transsexuals selected for Gender Reassignment
Surgery show relatively lower levels of psychopathology, both pre and after surgery.
Monteiro (2002) identified significant differences between the various phases of the
gender reassignment process. The results of her study refer to higher levels of lower
professional adaptation, social introversion, low self esteem, anti-social and aggressivesadist personality, and psychopathy in the group of transsexuals who had not yet initiated
hormonal treatment and the real life test. These conclusions refute what is evidenced in
clinical practice and the valuing of carrying out the process of sex reassignment by stages.
Monteiro (2002), highlighted significant differences between the various phases of sexual
reassignment process, in transsexuals. The results of her study refer a higher work
maladaptation, social introversion, low self-esteem, psychopathy, antisocial behavior and
- 114 -
aggressive-sadist levels in the group of transsexuals before starting hormone therapy and
the Real Life Experience. These conclusions rebut what can be observed in clinical practice,
and the appreciation of the sexual reassignment process that should be followed according
to various elements and steps. After a rigorous assessment procedure it is essential to
maintain a continuous psychotherapeutic process, integration in groups of transsexuals,
proper endocrinological therapy, and experience of the real life test for a minimum period
and for the adequate surgical procedures to take place only if all requirements are met.
Ross and Need (1989) studied the various social and psychological aspects in postsurgery transsexuals. They found better social adaptation and, in the majority of those
studied, also found lower rated of psychopathology, after gender reassignment surgery. The
authors concluded that the psychopathology presented by transsexuals is rather a
consequence of transsexualism itself. In 1980, Evelyn had already made this reality clear,
demonstrating lower rates of reported anxiety, in a study of the psychological aspects pre
and post surgery.
As a whole, the results of gender reassignment are satisfactory in approximately two
thirds (Abramowitz, 1986) to 90% of the cases (Green & Fleming, 1990). These dada apply
to both M-F and F-M transsexuals and include all the types of interventions required,
namely psychological, hormonal and surgical interventions. However, a study by Pauly
(1981) emphasizes better post-surgical adaptation in F-M transsexuals, with favorable
results being ten times more frequent than unfavorable results. The literature on follow-up
studies tends to suggest that surgical changes have positive consequences. According to
Michel et al. (2002), in the majority of cases, transsexuals are very satisfied with the results
of the interventions to which they have been submitted, and any difficulty that may arise is
- 115 -
usually temporary and disappears one year after the surgery. Various studies show that less
than 1% regret, and little more than 1% of suicide rate, amongst those who have undergone
surgery. Green (2007) emphasizes a generally superior quality of life of those who have
completed the gender reassignment process, when compared to the time before surgery.
According to Carroll (2000), the majority of studies evidence success in social,
psychological and vocational adaptation. Such positive results demonstrate the dominance
of successful outcomes in personal satisfaction, personal interactions and mental health.
However, financial success typically lags behind.
The follow-up studies of gender reassignment show, that in general, transsexuals
show improvement in social, professional and sexual adaptation , and practically all of
them are happy with having undergone gender reassignment surgery (Gomez Gil, Nogués,
Perpiná & Rabassó, 2001), thus suggesting long term stable psychological functioning
(Smith, Cohen & Cohen-Kettenis, 2002). Cuypere et al. (2006) emphasize the positive
changes experienced in social and in family life.
The clinical symptoms of
psychopathology and the levels of social adaptation are modified as a function of the levels
of post-surgery satisfaction/dissatisfaction post-surgery. However depression is a common
event and the quality of relationship may decline as a consequence (Barrett, 1998).
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CHAPTER THREE
RESEARCH METHODOLOGY
Following the analysis of the literature review we’ve encountered several studies
that have been developed in which personality profile, psychopathology and social
adaptation are concerned. The evidence of personality disorders and some associated
characteristics to Gender Identity Disorder is consistent. Personality factors are important
prognostic indicators, reassignment surgery success or unsuccess. The various dimensions
of psychopathology and social adaptation are also eminent, showing to be changeable, and
must be considered during the Sexual Reassignment Process.
Several authors describe changes in clinical psychopathology symptoms and social
adaptation following Sexual Reassignment Surgery but what about the personality pattern?
In which the personality profile is concerned, the controversy is still there, and there is no
research to answer it. This is a subject in which many studies are still to be done that might
effectively contribute for a better understanding of transexualism.
This research aims to provide evidence of changes in the Personality Profile,
Psychopathology and Social Adaptation in a group of transsexuals between the clinical
evaluation for the diagnosis confirmation and after Sexual Reassignment Surgery. The
value of this information might benefit the course of this process and clarify the strategies
to adopt in clinical practice with transsexual patients in a more solid way. The
psychological consequences of Sexual Reassignment Surgery are the real clinical question
that should be answered by research.
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Study characterization
Initially a prospective and descriptive study of the transsexuals group preceding
Sexual Reassignment Surgery, followed by a comparative study performed at the Clinical
Sexology Department, Hospital Júlio de Matos, Lisbon, Portugal. This comparative study
aims to compare the personality profile, psychopathology and social adaptation within the
same group of transsexuals before and after Sexual Reassignment Surgery (n=22). Besides
a semi-structured interview, other self-assessment instruments were used: Symptom-Check
–List-90 Revised (SCL-90), Beck Depression Inventory (BDI), Sociofamily Life
Questionnaire, Millon Multiaxial Clinical Inventory - II (MCMI-II), Minnesota Multiphasic
Personality Inventory – 2 (MMPI-2).
Ethical considerations
The participants in this study were informed about the objective of the evaluation,
and their Express written consent was obtained, signing the Informed Consent Form (see
Appendix C-I), being all data collected treated in an anonymous and confidential way.
Their cooperation was voluntary.
Sample
We have investigated a non randomized sample, i.e., a convenience sample, of 22
individuals, of both genders, with the diagnosis of Gender Identity Disorder that have
completed the process of sexual reassignment (in Portugal, and in line with the international
guidelines - Standards of Care of the International Harry Benjamin Gender Dysphoria
Association. – HBIGDA – WPATH ) which involve the five fundamental elements:
i. Diagnosis set-up – Clinical evaluation
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ii. Psychotherapy
iii. Real-life Experience
iv. Hormone Treatment
v. Surgery
All the individuals were evaluated in two moments:
i. Moment 1 (M1) – Clinical Evaluation for the diagnosis of Gender Identity
Disorder set-up.
ii. Moment 2 (M2) – after Sexual Reassignment Surgery.
Therefore two groups form the sample:
i. Group 1 – diagnosis of gender Identity Disorder (DSM-IV-TR, APA,
2000) at M1, n=22, followed at the Clinical Sexology Department as
outpatients.
ii. Group 2 – previous diagnosis of Gender Identity Disorder (DSM-IV-TR,
APA, 2000), n=22, at M2, referring to the same individuals as group 1 after
Sexual Reassignment Surgery.
Inclusion Criteria
Both genders and schooling (able to read and write – self-assessment instruments)
Exclusion Criteria
Absence of differential diagnosis, age below 18 yo, and non-acceptance of the
Informed Consent.
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Study Objectives
In this group of 22 individuals, of both genders, divided by two moments of
evaluation, this study is further sub-divided in two parts in which its objectives are
concerned:
i. The first objective is to determine in this group of transsexuals at M1
(Clinical Evaluation), with the aim of exploring and describe:
personality profile, also establishing the prevalence of personality
disorders;
level of social adaptation;
clinical psychopathological symptoms.
ii. Later on, with a comparative intention, it aims the correlation of the
previous results referring to M1 (Clinical Evaluation), comparing them
similarly with the results obtained at M2 (after the surgical procedures),
adopting the same method of evaluation and analysis.
Research Hypothesis
Facing the above mentioned objectives, the following hypothesis were formulated:
H1 – Borderline, Avoidant and Depressive Personality Disorders prevail in
the Gender Identity Disorder;
H2 – Gender differences
i. Higher frequency of Personality Disorders in male transsexuals
when compared to female transsexuals;
ii. Better general social adaptation in female transsexuals when
compared to male transsexuals;
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H3 – Differences between M1 e M2
i. Higher frequency of Personality Disorders in transsexuals at M1
when compared to the same group of transsexuals at M2;
ii. Significative differences in personality patterns of transsexuals at
M1 when compared to M2;
iii. Significative psychopathological differences in the results of
evaluation at M1 when compared to the evaluation at M2;
iv. Better general social adaptation of transsexuals at M2 when
compared to M1.
Definition of Study Variables
Besides a specific interview, other self-assessment instruments were used,
Symptom-Check –List-90 Revised – SCL 90 (Derogatis, 1977), as a general psychiatric
scale; the Beck Depression Inventory – BDI (Beck, 1961), as a depression scale; the
Sociofamily Life Questionnaire (Cooper, Osborn, Gath & Feggeter, 1982), as a scale of
social adaptation; the Millon Multiaxial Clinical Inventory – MCMI-II (Millon, 1987) and
the Minnesota Multiphasic Personality Inventory – 2 – MMPI-2 (Hataway & Mckinley,
1989), as a personality scales. It has been previously positively emphasized the
participation into this study, ensuring and reinforcing anonymity and confidentiality, as
well as the right to give up at any moment.
Interview
Specifically designed clinical interview taking the subject of transexuality into
account, and used in a way to build up the conception and to establish empathy with the
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transsexual subjects, essential to enable addressing such a subject as transexuality (see
Appendix C-II).
This instrument of hetero-evaluation used does not assume a particularly important
mistake due to the fact it has been quoted by the same person. Therefore a session to test
accuracy between evaluators was not needed.
This interview allowed accessing and collecting data of their personal history in a
specific and detailed manner, allowing in parallel an appropriate environment for the set up
of questionnaires. Apart from the sociodemographic data, other components of their
personal history, psychosexual development, family history, beginning and course of
disease, mental exam, objectives and motivations are also assessed.
Questionnaires
One of the criteria of preference when choosing the instruments is based on the fact
they are self-assessment scales, allowing us to reduce the emergence of mistakes when
quoting the observed variables by the interviewer and reported by the subject, and also
allowing us to compare these results with other results from different studies done in this
field.
The instruments used in this study aim a quantified evaluation of personality, of
psychopathology and the level of social adaptation. The selection was determined taking
our proposed objectives into account and also according to the subjects analyzed in this
study.
All the proceedings were duly explained in which the filling of the self-assessment
scales is concerned, and in case of any doubts and/or special needs, they would be clarified
and repeated, not changing, by all means, their content.
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Symptom-Check –List-90 Revised – SCL 90
Developed by Degoratis, in 1977, the Symptom-Check-List-90-Revised (SCL-90) is
a self-assessment scale that covers major dimensions of general psychopathology (see
Appendix C-III). Prof. Américo Baptista assessed this scale for the Portuguese population
in 1987.
This
questionnaire
consists
of nine scales:
“Somatization”,
“Obsession-
Compulsion”, “Interpersonal Sensivity”, “Depressivity”, “Anxiety”, “AggressivenessHostility”, “Phobic Anxiety”, “Paranoid Ideation”, and “Psychoticism”. The nine scales
correspond to different primary dimensions of psychopathologic symptoms that, on their
turn, may exist isolated or associated within the same individual. The questionnaire also
exhibits a “General Symptoms Index” and identifies some symptoms, called “Positive
Symptoms” related to appetite, sleep, suicide ideation and guilt. The “General Symptoms
Index” and the “Positive Symptoms” allow us a better flexibility in the global assessment of
the psychopathological profile of the individual.
Degoratis describes the nine primary dimensions in the following way:
i. “Somatization”. Scale formed by twelve items that reflect elevations
related to the individual perception of the somatic functioning. It includes
complaints focused into the cardiovascular, gastrointestinal, respiratory
systems, headaches, sweating, shortage of breath, pain and muscular
discomfort and/or other somatic equivalents of anxiety.
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ii. “Obsession-Compulsion”. Scale formed by ten items that includes
symptoms that are frequently identified with the obsessive-compulsive
syndrome. This dimension gathers the thoughts, impulses and actions
experienced in a persistent manner and to which the subject cannot resist,
being experienced as egodystonic and unwanted. It also includes behaviors
and experiences of general cognitive difficulties.
iii. “Interpersonal Sensivity”. Scale formed by nine items. It exhibits as the
main goal to focus on inferiority feelings or personal inadequacy, mainly in
which other people are concerned. This dimension includes various
manifestations: depreciation, doubt, discomfort, timidity and negatives
expectations.
iv. “Depressivity”. Scale formed by thirteen items which include various
clinical symptoms of the depressive syndrome, such as affection symptoms,
dysphoric humor, signs of isolation, lost of interest in life, lack of energy and
demotivation. We can also find in this dimension items referring desperation
feelings, suicidal thoughts and other cognitive related.
v. “Anxiety”. Scale formed by ten items resulting from the association of
symptoms and behaviors junction clinically related to expressed anxiety. It
gathers general indicators of agitation, jitters, and tension, cognitive signs of
anxiety, and symptoms of general anxiety as well as panic attacks.
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vi. “Hostility”. Scale formed by six items focused on thoughts, feelings and
behaviors characteristic of the negative affective condition of cholera,
expressed through negative emotions like anger, aggression, irritability and
resentment.
vii. “Phobic Anxiety”. Scale formed by seven items that reflect dimensions
of the most pathognomonic and disruptive of phobic behavior. Phobic
anxiety expresses itself through the experience of an unpleasant emotion that
involves a persistent fear reaction to a certain person, object, place or
specific situation, characterized by its irrationality and disproportion related
to the trigger stimulus, leading to an avoidant behavior.
viii. “Paranoid Ideation”. Scale formed by six items, in which paranoid
behavior is faced as a disturbed way of thinking, and all items are in
accordance with this conceptualization. As a reflex f this disorder, it exhibits
as major features: projective thoughts, hostility, suspicion, egocentrism, fear
of autonomy loss and delusion.
ix. “Psychoticism”. Scale formed by ten items referring to isolation and
schizoid lifestyle, also indicating of primary symptoms of schizophrenia, like
hallucinations and control of thoughts. This dimension delivers a continuum,
in a gradation from interpersonal isolation to a clear evidence of a psychosis.
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Seven items that are not included in any of these previous dimensions form the scale
“Additional Items”. They belong to various dimensions and these items are not specific of
any of them.
This questionnaire allows to measure in parallel, through the symptoms found in
any of these different dimensions, psychopathological traces of personality.
Each of the subscales enables to determine a psychopathological profile, once it
reflects a valid measure and sensitive to the psychopathological changes mentioned. The
total score corresponds to a measure of the general psychopathological condition.
Assessment studies performed have established thresholds for “normality” and “pathology”.
SCL-90 is considered a valid instrument for the quick and systemic screening of
psychopathologic altered conditions and it contributes to the set up of a diagnosis. It’s
frequently used in research, since it delivers sensible quantification to inter and
intraindividuals changes.
Beck Depression Inventory – BDI
Developed by Aaron Beck and col in 1961, the Beck Depression Inventory (BDI) is
a self-assessment scale that aims to evaluate in an objective and profound way the behavior
changes due to a depressive condition. (see Appendix C-IV)
This inventory is formed by 21 categories, distributed by symptoms and attitudes
using four or five statements, which intensity varies from 0 and 3 and, accordingly, which
of these statements will evoke a raising degree of depression severity. These items refer to
sadness, pessimism, feeling of failure, lack of satisfaction, feelings of guilt, punishment
sensation, self-depreciation, self-accusation, suicidal thoughts, crying fits, irritability, social
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retraction, indecision, body image distortion, working inhibition, sleep disturbances, fatigue,
loss of appetite, weight loss, concerns and decrease in sexual desire.
The individual must point out the most appropriate alternative from his/her point of
view. Following the sum of these values a final score is reached, therefore classified in one
of the following conditions:
Below normal, probable denial (0-4);
Not significative (5-12);
Mild depression (13- 20);
Moderate depression (21-25);
Severe depression (26-36)
Sociofamily Life Questionnaire
Developed from an original American version to use with the British population by
Cooper, Osbon, Gath e Feggeter in1982, the Sociofamily Life Questionnaire is an
instrument in which the social adaptation is self-assessed. (see Appendix C-V)
It’s a simple instrument, easy to administer and it evaluates the individual
adaptation in various social roles:
Employment;
Domestic functioning;
Social activities and leisure time;
Relationship with the extended family;
Relationship with the spouse;
Relationship with the children;
Relationship with the nuclear family while a global unit.
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The assessment is made in a Liket-type scale, varying from 1 to 5, the highest
punctuation being the highest misfit.
This instrument was chosen for its ease of use, having demonstrated as an adequate
measure of social adaptation throughout the time and for its sensivity to differences
between the groups. It’s also an easy instrument to establish correlation between social
adaptation and other psychological variables (Cooper et al. 1982).
Millon Clinical Multiaxial Inventory – MCMI-II
Developed by Millon in 1987, the Millon Clinical Multiaxial Inventory (MCMI-II)
it’s a personality questionnaire covering personality disorders included in DSM-III-R. (See
Appendix C-VI)
This questionnaire consists of 175 items with a Right/Wrong answers format and
takes an administration time fairly short (15 to 25 minutes).
26 scales cover the various features of pathological personality:
i. Four scales and Validity Indexes
Validity
Honesty
Desirability
Modification
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ii. Ten Personality Scales – Basics
Schizoid
Phobic
Dependent
Histrionic
Narcissistic
Antisocial
Agressive-sadic
Compulsive
Passive-aggressive
Self-destructive/masochist
iii. Three Scales of Personality Disorders
Schizotypical
Borderline
Paranoid
iv. Six Scales of Clinical Disorders – moderate intensity (Axis I, DSM-III-R)
Anxiety
Hysteriform
Hypomania
Dysthymia
Alcohol abuse
Drugs abuse
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v. Three Scales of Clinical Disorders – severe intensity (Axis I, DSM-III-R)
Psychotic thinking
Major depression
Delirious disorder
The Minnesota Multiphasic Personality Inventory – 2 – MMPI- 2
Developed by Hataway e McKinley in 1989, The Minnesota Multiphasic
Personality Inventory – 2 (M.M.P.I.-2) is a questionnaire based on the previous M.M.P.I.
version. It aims to evaluate the various personality factors or features, allowing us to
determine a personality profile. (See Appendix C-VII)
This updated version is perceived as a more complete one, reveals important and
positive changes at the items level, new content elements not included in the original
M.M.P.I. version, additional validity indicators and additional scales, and new categories
for the T scores at the different scales. The most significant changes are a more
representative characterization of modern society and also a more consistent format at the T
score of basic profile level of the questionnaire.
One can use it both individually or in-group. The filling takes a variable time,
between 60 to 90 minutes.
567 items, on a random mode, with a true or false answer, form the questionnaire.
It exhibits three groups of scales: clinical (“Hypochondriasis”, “Depression”, “Hysteria”,
“Psychopathic
Deviate”,
“Masculinity-femininity”,
“Paranoia”,
“Psychasthenia”,
“Schizophrenia”, “Hypomania” and “Social Introversion”), of content and supplementary.
It also includes a group of scales referring to validity (“?”, “L”, “F”, “K”, “Fb”, “TRIN”,
“VRIN”) and other additional ones.
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i. Clinical Scales
Hs - “Hypochondriasis”. Some of these items in this scale reflect
specific symptoms or complaints, while others refer to a general somatic
discomfort or a self-centered attention.
D - “Depression”. This scale refers not only to discouragement
feelings, pessimism and desperation that characterize the clinical features of
depressed individuals, but also to basic personality characteristics, like
extreme responsibility, rigid personal values and self-penitence. It exhibits as
areas of content - subscales: subjective subjective depression (D1),
psychomotor retardation (D2), physical malfunctioning (D3), mental
dullness (D4) and brooding (D5).
Hy - “Hysteria”. This scale indicates specific physical complaints
and problems denial at the individual’s life or the absence of social anxiety.
It exhibits as areas of content - subscales: denial of social anxiety (Hy1),
need for affection (Hy2), lassitude – malaise (Hy3), somatic complaints
(Hy4) and inhibition of aggression (Hy5).
Pd - “Psychopathic Deviate”. This scale refers to individuals’ mood
to recognize problems with the Law or authority, to the absence of
consideration in relation to the great majority of social and moral standards.
It exhibits as areas of content - subscales: family discord (Pd1), authority
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problems (Pd2), social imperturbability (Pd3), social alienation (Pd4) and
self-alienation (Pd5).
Mf - “Masculinity-femininity”. Scale of attitudes, interests,
emotional reactions and feelings related to work, social relations and
affections.
Pa - “Paranoia”. Scale that reflects a marked interpersonal sensivity
as well as a trend to misinterpret the reasons or intentions from others. It also
includes, egocentrism and insecurity. It exhibits as areas of content subscales: persecutory ideas (Pa1), poignancy (Pa2) and naiveté (Pa3).
Pt - “Psychasthenia”. Scale which refers to the obsessive, compulsive
symptoms, and exaggerated fears; more generalized anxiety and stress (or
emotionally negative); strict moral standards; blame; rigid effort to control
impulses.
Sc - “Schizophrenia”. Scale that covers a great variety of weird
thoughts, rare experiences and special sensitive characteristics of individuals
with various forms of schizophrenia. It exhibits as areas of content subscales: social alienation (Sc1), emotional alienation (Sc2), three
measures of lack of ego mastery (cognitive – Sc3, conative – Sc4, and
defective inhibition – Sc5) and bizarre sensory experiences (Sc6).
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Ma
-
“Hypomania”.
Scale
encompassing
some
behavior
characteristics and traces associated to maniac-depressive disorder. It
exhibits as areas of content - subscales: amorality (Ma1), psychomotor
acceleration (Ma2), imperturbability (ma3), and ego inflation (Ma4).
Si - “Social Introversion”. Scales that refers to the levels of social
isolation and social reserve, as well as social assertiveness. It exhibits as
areas of content - subscales: shyness/self-consciousness (Si1), social
avoidance (Si2), and alienation – self and others (Si3).
ii. Supplementary Scales - Traditional
A - “Anxiety”. Indicates the levels of anxiety.
R - “Repression”. Indicates the levels of repression.
Es - “Ego strength”. Measure of adaptability, resistance, personal
resources and affective behavior. It’s also a good indicator of general mental
health.
MAC-R - “MacAndrew-Revised”. Indicates the levels of alcohol and
substances abuse.
iii. Supplementary Scales - Additional
O-H - “Overcontrolled Hostility”. Measure of an individual’s ability
to tolerate without retaliation.
Do - “Dominance”. Measure of an individual’s tendency to
predominance and control of his/her interpersonal relations.
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Re - “Social responsibility”. Indicates the levels of social
responsibility.
Mt - “College Maladjustment”. Indicates the levels of University
Inadequacy.
GM - “Gender Role-Masculine”. Indicates the levels of Masculine
Gender Role.
GF - “Gender Role-Feminine”. Indicates the levels of Feminine
Gender Role.
PK / PS - “Post-traumatic Stress Disorder”. Additional measure
which allows the identification various subgroups of men and women with
this emotional disorder. Besides being independent, they can be used
together for a better diagnostic clarification.
MDS - “Marital Distress”. Indicates the levels of marital distress.
APS - “Addiction Potential”. Indicates the abuse of substances. These
items are correlated with personality dimensions and vital situations
associated with substance abuse.
AAS - “Addiction Admission”. Complement that indicates substance
abuse.
iv. Content Scales
Descriptive and predictive scales of personality variables.
ANX - “Anxiety”.
FRS - “Fears”.
OBS - “Obsessiveness”.
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DEP -“Depression”.
HEA - “Health Concerns”.
BIZ - “Bizarre Mentation”.
ANG - “Anger”.
CYN -“Cynicism”
ASP - “Antisocial Practices”.
TPA - “Type A”.
LSE - “Low Self-Esteem”.
SOD - “Social Discomfort”.
FAM - “Family Problems”.
WRK - “Work Interference”.
TRT - “Negative Treatment Indicators”.
v. Validity Scales
? – (CNS) “Cannot Say”. This scale refers to a group of items
answered by the individual, as “I don’t know”. The highest the score in this
scale the lowest capacity shown to discriminate the scales of the
questionnaire.
Scale ? – (CNS) “Cannot Say”
PD 0-1, valid
PD 2-10, probably valid
PD11-29, questionable validity
PD ≥ 30, probably invalid
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L - “Lie”, with the aim to evaluate the individual’s probability of
having this attitude. Used as a probability index that a certain protocol might
have been jeopardized by a particular style in answering to the questionnaire.
Scale L - “Lie”
PD < 50, probable bad image attitude
PD 50-59, valid
PD 60-69, probably valid
PD70-79, questionable validity
PD ≥ 80, probably invalid
F - “Infrequency”. Considered answers at random, showing the
possibility of a non-cooperation by the individual, pretending he/she has
filled the questionnaire, not having true reading ability, a weak contact with
reality or deliberately exaggerate his/her problems or disorders.
Escala F - “Infrequency”
PD < 50, acceptable form
PD 50-59, acceptable form
PD 60-64, probably valid
PD 65-79, probably valid
PD 80-100, invalid. If valid, consider serious
psychopathology
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K - “Correction”. Considered as a correction scale, and the best
validity indicator. A high score in this scale may invalidate the profile
Scale K - “Correction”
PD < 50, invalid
PD 50-59, valid
PD 60-70, questionable validity
PD > 70, invalid
The clinical scales isolated cannot invalidate the profile, show the origin of
punctuation and raise hypothesis for interpretation.
vi. Additional Validity Indicators
Fb – “Back F”. Additional proof of acceptability of the answers,
mainly for the additional and content scales.
Scale Fb - “Back F”
PD < 50, questionable validity
PD 50-64, normative scores
PD 65-79, questionable validity
PD 80-100, invalid
PD> 100, invalid
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TRIN - “True Response Inconsistency” / VRIN - “Variable
Response Inconsistency”. Scales that complete the L, F and K in a unique
and useful manner. In these scales the scores are direct.
TRIN Scale
VRIN Scale
PD < 9, valid
PD ≤ 14, valid
PD 9-13, valid
PD > 14, invalid
PD > 14, invalid
Procedures
Group 1 is investigated in the frame of their clinical evaluation aiming to get a
diagnosis of Gender Identity Disorder, at the Clinical Sexology Department, Hospital Júlio
de Matos, Lisbon, Portugal, and later on, group 2 is assessed, not on a clinical context, after
Sexual reassignment Surgery, according to the same assessment protocol.
Statistical Methodology
The statistical procedures were done using the Statistical Package for Social
Sciences – PASW 18 software.
We’ve calculated the descriptive statistics, mean, standard deviation, frequencies
and percentages, according to the type of variable.
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In order to verify whether the interval and ratio variables of the socio-demographic
data, as well as the dimensions of the scales presented a normal distribution, we’ve also
performed the Kolmogorov-Smirnov test. According to the fact that some of the variables
did not show a normal distribution (p≤. 05), non-parametric studies were also used, like the
Mann-Whitney (U) test. Yet, for the dimensions that have showed a normal distribution
(p>. 05) and in those in which homogeneity of variances does exist (through Levene test),
the investigation of its differences according to the group or other nominal or ordinal
variables, parametric studies were also used, like the T-Student test (t). In the case of
categorical variables, the differences in proportion between the two Moments were also
studied, using the proportion differences test (Z).
To investigate the correlation between variables we’ve used Spearman’s bivariate
correlation (rho) for the variables that have not shown a normal distribution and Pearson’s
(r) for those variables that have shown a normal distribution and homogeneity of variance.
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Chapter Four
Presentation of Results
Clinical Interview
Descriptive statistics of the socio-demographic variables according to the Moment
The analysis is representative of sixteen transsexuals F-M (%= 72.7) and six M-F
(%=27.3).
Género
Gender
27,3
M-F
F-M
72,7
Graphic 1 – Gender
At the Clinical Evaluation Moment, M1, the majority of this sample, with an
average age of 27.09 years (S.D. 10.438), declared living in Lisbon and Vale do Tejo
region (N= 13; %= 59.1), attending or holding a high school/university degree (N= 12; %=
54.5), and being professionally active (N= 15; %= 68.2). In accordance with Graffar
Professional level, the distribution is bimodal with maximums on level 1 (N= 5; %= 22.7)
and on level 5 (N= 5; %= 22.7). About the majority of the sample, 59.1% reported not
having toxic habits, which correspond to thirteen individuals.
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Nineteen individuals of this sample declared to be single (%= 86.4) and eleven
reported to have a stable relationship, which correspond to 50%. Out of these ones, six
reported a stable relationship for 3 or more years (%= 27.3).
Concerning the existence of children, the majority alleged not having children (N=
19; %= 86.4). Those who claimed having children, these were their biologic children.
Regarding their phratry position, nine individuals (%= 40.9) alleged to be the
youngest child, with an average number of brothers of 2.05 (S.D.= 1.812).
(See Table 1 and Table 2 – Appendix D)
After Sexual Reassignment Surgery Evaluation Moment, M2, some change were
observed when compared to M1 on the following variables: average age increased to 33.5
years (S.D.= 10.004); Academic Qualifications: the proportion of individuals who attend or
hold a high school/University degree has changed (N= 10; %= 45.5) and the proportion of
university studies has increased (N= 8; %=36.4); Professional situation: the proportion of
individuals professionally active has also increased (N= 21; %= 95.5) and Graffar level 1
became the major one (N= 8; %= 36.4). In which regards toxic habits, changes were also
observed: 63.4% of the sample denied any toxic habits, which correspond to fourteen
individuals.
In M2, sixteen individuals of the sample alleged to be single (%= 72.7) and thirteen
reported a stable relationship, which correspond to 59.1%. Out of these, nine declared to be
involved in a stable relationship for 3 or more years (%= 40.9).
Concerning children, an increase in the number of children was observed, although
not biological children, when compared to M1. However, the majority of the sample, in M2,
declared not having children (N= 15; %= 68.2). Among those who declared the existence of
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children, three referred to them as their biological children (%= 13.6), three belonging to
their partner (%= 13.6), and one adopted (%= 4.5).
(See Table 1 and Table 3 – Appendix D)
Descriptive statistics of the clinical variables at Moment 1
The total sample is representative of a karyotype, in all individuals, according to
their biological sex (%=100.0).
At M1, the entire sample (N= 22; %= 100.0) was in a Clinical Evaluation stage of
their Sexual Reassignment Process (SRP). Those twenty two individuals started their SRP
between 2001 and 2006, the majority (N= 7; %= 31.8) in 2001, and five of them (%=
22.7%) in 2006.
After the Clinical Evaluation, at M1, the entire sample fulfilled the diagnostic
criteria of Gender Identity Disorder – GID (%= 100.0) and, at a differential diagnosis level,
no co-morbidities were reported, inasmuch none was verified (%= 100.0).
The majority of the individuals reported psychiatric intervention, (N= 13; %= 59.1),
eight of those (36.4%) with the diagnosis of Depressive Disorder with associated comorbidities of Anxiety Disorder and Personality Disorder. Psychotherapy intervention was
applied to the whole sample (%= 100).
The majority of the individuals (N= 12; %= 54.5) declared psychotropic intake.
Among those, anxiolytics and/or antidepressants (%= 54.5); none of them has ever taken
antipsychotics (%= .0).
(See Table 4 – Appendix D)
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Descriptive statistics of the clinical variables at Moment 2
At M2, the whole sample (N= 22; %= 100.0) was in Post-Sexual Reassignment
Surgery phase. The majority of the sample (N= 14; %= 63.6) declared their SRP as
complete, corresponding to an average of 6.64 years of duration of their entire process
(S.D.= 1.393). Eight of these individuals, refer to their status as in the Lawsuit Phase of
their SRP (%= 36.4), waiting for the Legal Recognition, in order to have their SRP duly
completed.
The majority of the individuals declared the need for psychiatric care (N= 14; %=
63.6) throughout their SRP; out of these fourteen patients, eight (%=36.4) were treated for
Depressive Disorder with Anxiety Disorder and Personality Disorder as co-morbidities.
The psychiatric care was considered as complete in 40.9%, maintained in 18.2% and
discontinued in 4.5% of the individuals. The psychotherapy intervention was still ongoing
on the majority of the sample (%= 72.2), with different periodicity according the individual
therapeutic needs.
The majority of the individuals (N= 18; %= 81.8) referred not taking any
psychotropic drugs. On the other hand, those who reported the intake of these drugs (N=
4; %= 18.2), were medicated with anxiolytics and/or antidepressant (%= 18.2); no one has
ever taken any antipsychotic drug (%= .0).
(See Table 4 and Table 5 – Appendix D)
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Symptom-Check –List-90 Revised – SCL 90
The tests performed to investigate the presence, or not, of significant differences
between Moments (M1 e M2) were parametric or not parametric, according to the statistics
found in the Normality tests (Kolmogorov-Smirnoff) and Homoscedasticity (Homogeneity
of Variance) (Levene).
Differences on primary dimensions of SCL-90 and on the general index of symptoms
SCL-90 according to the Moment
1,2
SCL-90
1
Mean
0,8
M1
0,6
M2
0,4
0,2
om
s
Sy
m
pt
ot
ic
ism
ex
of
In
d
Ps
yc
h
at
io
n
Ge
ne
ra
l
Id
e
nx
ie
ty
Pa
ra
no
id
y
Ph
ob
ic
A
Ho
sti
lit
ie
ty
An
x
So
m
Ob
at
se
iza
ss
tio
io
n
nCo
m
In
pu
te
lsi
rp
on
er
so
na
lS
en
siv
ity
De
pr
es
siv
ity
0
***P≤
≤ .OO1; ** P≤
≤ .O1; *P≤
≤ .O5
Graphic 2 – SCL-90 Primary Dimensions and General index of symptoms
Were found differences statistically significant in the following variables:
• Interpersonal Sensivity T= 2.76*; M1 shows a higher average (M= .993;
S.D.= .909) than M2 (M= .471; S.D.= .336). However, these differences weren’t significant
when each gender was analyzed in particular.
- 144 -
• Depressivity T= 2.79*; M1 show a higher average higher (M= 1.003; S.D.= .915)
than M2 (M= .479; S.D.= .373). However, when analyzed for each gender, those
differences were only significant in the group M-F.
• Anxiety T= 3.95***; M1 show a higher average (M=.836; S.D.= .777) than M2
(M= .300; S.D.= .281). In this case, when analyzed each gender in particular, those
differences were significant in both groups, F-M and M-F.
• Hostility T= 2.18*; M1 show a higher average (M= .594; S.D.= .805) than M2
(M= .256; S.D.= .260). However, these differences weren’t significant when each gender
was analyzed in particular.
• Phobic Anxiety T= 2.29*; M1 show a higher average (M= .512; S.D.= .616) than
M2 (M= .180; S.D.= .400). However, when analyzed for each gender in particular, those
differences were only significant in the group M-F.
• Paranoid Ideation T= 2.35*; M1 shows a higher average (M= 1.030; S.D.= .868)
than M2 (M= .551; S.D.= .566). However, when analyzed each gender in particular, those
differences were only significant in the group M-F.
• Psychoticism T= 3.27**; M1 shows a higher average (M= .696; S.D.= .731) than
M2 (M= .273; S.D.= .291). However, when analyzed each gender in particular, those
differences were only significant in the group M-F.
• General index of the Symptoms T= 3.05**; M1 shows a higher average (M= .858;
S.D.= .724) than M2 (M= .429; S.D.= .320). However, when analyzed for each gender in
particular, those differences were only significant in the group M-F.
- 145 -
In the case of the variable Somatization, no significant differences were found in the
total groups (TG) of individuals. However, when analyzed each gender in particular, those
differences were significant in the group M-F.
(See Table 6 – Appendix D)
Differences in additional items of SCL-90 according to the Moment
SCL-90
2,5
Mean
2
1,5
M1
M2
1
0,5
Graphic 3 – SCL-90 – Additional Itens
Feelings
of Guilt
Restless
Sleep
Sleep
A.M.
Appetite +
Death
Thoughts
Sleep
P.M.
Appetite -
0
***P≤
≤ .OO1; ** P≤
≤ .O1; *P≤
≤ .O5
The following statistically differences were found in the variables:
• Appetite - T= 3.36**; M1 shows a higher average (M= 1.36; S.D.= 1.329) than
M2 (M= .450; S.D.= .739). In this case, when analyzed each gender in particular, those
differences were significant in both groups, F-M and M-F.
• Sleep P.M. T= 4.20***; M1 shows a higher average higher (M= 1.95; S.D.=
1.327) than M2 (M= .68; S.D.= .894). In this case, when analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F.
- 146 -
• Death Thought T= 5.64***; M1 shows a higher average (M= 1.41; S.D.= 1.054)
than M2 (M= .18; S.D.= .395). In this case, when analyzed for each gender in particular,
those differences were significant in both groups, F-M and M-F.
• Appetite + T= -2.42*; M1 shows a lower average (M= .14; S.D.= .468) than M2
(M= .68; S.D.= 1.041). However, the differences weren’t significant when analyzed each
gender in particular.
• Sleep A.M. T= -2.99**; M1 shows a lower average (M= .32; S.D.= .894) than M2
(M= 1.18; S.D.= 1.368). However, when analyzed each gender in particular, those
differences were only significant in the group F-M.
• Restless Sleep T= 4.42***; M1 shows a higher average higher (M= 1.64; S.D.=
1.217) than M2 (M= .50; S.D.= .74). In this case, when analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F.
The remaining variables didn’t exhibit, under any circumstances, significant
differences between the two Moments.
In the set of variables in which significant differences between the two Moments
were found, M1 indexes are higher in all variables except in appetite + and sleep A.M.
When significant differences do exist between M1 and M2, whenever we perform an
analysis just for one gender, those differences are always more significant in the M-F group.
(See Table 6 – Appendix D)
- 147 -
Descriptive statistics of the thresholds “normality” and “pathologic” in primary
dimensions and in the general index of symptoms SCL-90
according to the Moment
According to the thresholds “normality” (values under 1.5) and “pathologic” (values
equal or superior to 1.5), 9.1% (N=2), group1 shows values considered as pathological in
the somatization dimension, 18.2% (N=4) in obsession-compulsion, 22.7% (N=5) in
interpersonal sensivity; 31.8% (N=7) in depressivity, 13.6% (N=3) in anxiety, 4.5% (N=1)
in hostility, 9.1% (N=2) in phobic anxiety, 13.6% (N=3) in paranoid ideation, 9.1% (N=2)
in psychoticism and 13.6% (N=3) in the general index of symptoms. Group2, 4.5% (N=1)
exhibits values above the normality threshold in the somatization dimension, 4.5% (N=1) in
obsession-compulsion, 4.5% (N=1) in phobic anxiety and 4.5% (N=1) in paranoid ideation.
The remaining scores and the results of the other dimensions, in group2, were considered
within normality. (See Table 7 – Appendix D)
Differences in the threshold “normality” and “pathologic” in primary dimensions and
in general index of symptoms SCL-90 according to the Moment
They are significant differences in the proportion of cases labeled as ”Pathologic”
(values equal or superior to 1.5) in the two Moments, in the following variables:
Interpersonal Sensivity, Z = 2.37**, M1 shows a significant higher proportion (%= 22.7)
than M2 (%= .0); Depressivity, Z = 2.88**, M1 shows a significant higher proportion (%=
31.8) than M2 (%= .0).
In the remaining variables, in spite of the existence of differences in some of the
proportions of superior and/or inferior indexes, it wasn’t possible to conclude that those
were significant differences due to the reduced number of individuals in this study.
- 148 -
Beck Depression Inventory – BDI
The tests performed to investigate the presence, or not, of significant differences
between Moments were parametric or not parametric, according to the statistics found in
the Normality tests (Kolmogorov-Smirnoff) and Homoscedasticity (Homogeneity of
Variance) (Levene).
Differences in total BDI according to the Moment
BDI
BDI
13,23
14
Mean
Média
12
10
8
6
2,45
4
2
0
M1
M2
***P≤
≤ .OO1; ** P≤
≤ .O1
Graphic 4 – BDI – Total results
Concerning the total group of individuals, significant differences were found in the
averages of questionnaire BDI, T = 6.38***, between M1 (M= 13.23; S.D.= 8.596) and M2
(M= 2.45; S.D.= 2.324). In this case, when analyzing each gender in particular, these
differences were significant in both groups, F-M and M-F. (See Table 8 – Appendix D)
- 149 -
Differences in Depression level - BDI according to the Moment
According to the levels of depression in BDI, respecting the total group (TG) of
individuals, an inversion of the depressive behavior standard was observed between the two
Moments.
BDI
100
90
22,7
80
70
60
%
50
M2
77,3
40
68,2
M1
30
20
0
10
13,6
0
9,1
0
9,1
0
Severe
Depression
Moderate
Depression
Mild
Depression
Not
Significant
Below Normal
** P≤
≤ .O1
Graphic 5 – BDI – Depression Levels
There are significant differences in the proportion of subjects with Depression
between the two Moments, Z = 2.84**, since in M1 we can observe seven individuals (%=
31.8) with Depression, three of them classified as “severe” (%= 13.6), two “moderate” (%=
9.1) and two “mild” (%= 9.1), with the remaining fifteen “not significant” (%= 68.2), while
in M2, no cases of Depression were reported [“not significant” in five individuals (%=
22.7) and the remaining seventeen (%= 77.3) were classified as “below normal”]. (See Table
9 – Appendix D)
- 150 -
Sociofamily Life Questionnaire – QVSF
The tests performed to investigate the presence, or not, of significant differences
between Moments were parametric or not parametric, according to the statistics found in
the Normality tests (Kolmogorov-Smirnoff) and Homoscedasticity (Homogeneity of
Variance) (Levene).
Differences in the dimensions of QVSF according to the Moment
QVSF
QVSF
2,5
Mean
2,0
1,5
M1
M2
1,0
0,5
0,0
Employment
Domestics
Functioning
Social
Relationship Relationship Relationship
Activities
- Extended
with the
with the
and Leisure
Family
Spouse
Children
Time
Nuclear
Family
***P≤
≤ .OO1; ** P≤
≤ .O1; * P≤
≤ .O5
Graphic 6 – QVSF – Social Roles of individual adaptation
The following statistically significant differences were found in the variables:
• Employment T= 2.62*; M1 show a higher average (M= 1.771; S.D.= .641) than
M2 (M= 1.443; S.D.= .357). In this case, when analyzed each gender in particular, those
differences weren’t significant in either group.
- 151 -
• Social Activities and Leisure Time T= 2.47*; M1 shows a higher average (M=
1.927; S.D.= .942) than M2 (M= 1.436; S.D.= .330). In this case, when analyzed each
gender in particular, those differences weren’t significant in either group.
• Relationship with the Extended Family T= 4.43***; M1 shows a higher average
(M= 2.305; S.D.= .607) than M2 (M= 1.805; S.D.= .564). However, when analyzed each
gender in particular, those differences were only significant in the group F-M.
• Relationship with the Spouse T= 3.47**; M1 shows a higher average (M= 2.209;
S.D.= .536) than M2 (M= 1.679; S.D.= .408). However, when analyzed each gender in
particular, those differences were only significant in the group F-M.
(See Table 10 – Appendix D)
QVSF
QVSF
2
1,996
1,589
Mean
Média
1,5
1
0,5
0
M1
M2
***P≤
≤ .OO1
Graphic 7 – QVSF – Social Adaptation
Statistically differences were found in the variable:
• Social Adaptation T= 4.54***; M1 shows a higher average (M= 1.996;
S.D.= .573) than M2 (M= 1.589; S.D.= .296). However, when analyzed each gender in
particular, those differences were only significant in the group F-M.
- 152 -
No significative differences were observed in the remaining variables of QVSF, in
any situation, between the two Moments.
On set of variables in which significant differences occur between the two Moments,
M1 indexes are always higher. Whenever these significant differences exist between the
Moments, if we perform a subsequent analysis just for one gender, these differences are
always more significant in the group F-M.
(See Table 10 – Appendix D)
Millon Clinical Multiaxial Inventory – MCMI-II
The tests performed to investigate the presence, or not, of significant differences
between Moments were parametric or not parametric, according to the statistics found in
the Normality examinations (Kolmogorov-Smirnoff) and Homoscedasticity (Homogeneity
of Variance) (Levene).
Differences in MCMI-II scales according to the Moment
In which scales and validity indexes are concerned, statistically significant
differences were found on the variable:
• Sincerity T= 2.91** ; M1 shows a higher average (M= 55.73; S.D.= 21.75) than
M2 (M= 42.45; S.D.= 24.15). However, when analyzed each gender in particular, the
differences were only significant in the group M-F. (See Table 11 – Appendix D)
- 153 -
80
MCMI-II
70
60
Mean
50
M1
40
M2
30
20
10
Ag
ia
l
re
ss
iv
esa
di
c
Co
m
pu
Pa
l si
ss
ve
ive
-a
gg
re
ss
ive
Se
lfde
st
ru
ct
iv
e
ic
An
tis
oc
Na
rc
iss
i st
t
rio
ni
c
Hi
st
De
pe
nd
en
Ph
ob
ic
Sc
hi
zo
id
0
Graphic 8 – MCMI-II – Personality Scales - Basics
Regarding the personality scales - basics, no statistically significant differences
were found in the total group (GT) of the sample. (See Table 11 – Appendix D)
MCMI-II
MCMI-II
70
60
Média
50
40
M1
30
M2
20
10
0
Schizotypical
Graphic 9 – MCMI-II – Personality Disorders
Borderline
Paranoid
**P≤
≤ .O1
- 154 -
In which regards personality disorder scales, statistically significant differences
were found on the following variables:
• Paranoid T= 3.35** ; M1 shows a higher average (M= 63.41; S.D.= 23.14) than
M2 (M= 49.95; S.D.= 24.15). However, when analyzed each gender in particular, the
difference was only significant in the group F-M. (See Table 11 – Appendix D)
MCMI-II
MCMI-II
60
50
Mean
40
M1
30
M2
20
10
Ab
us
e
Dr
ug
s
Al
co
ho
lA
bu
se
ia
Dy
st
hy
m
an
ia
Hy
po
m
Hy
st
er
ifo
rm
An
xie
t
y
0
**P≤
≤ .O1; *P≤
≤ .O5
Graphic 10 – MCMI-II – Clínical Disorders – Moderate Intensity
Regarding the clinical disorders scales – moderate intensity, the following
statistically significant differences were found in the variables:
• Anxiety T = 2.24* ; M1 shows a higher average (M= 39.41; S.D.= 27.89) than
M2 (M= 23.36; S.D.= 28.29). However, when analyzed each gender in particular, these
differences were only significant in the group M-F.
- 155 -
• Hysteriform T= 2.18* ; M1 shows a higher average (M= 45.64; D.P.= 21.60)
than M2 (M= 34.82; S.D.= 23.25). However, the analysis of each gender didn’t reveal
significant differences for either group.
• Dysthymia T= 2.97** ; M1 shows a higher average (M= 38.64; S.D.= 30.16)
than M2 (M= 18.55; S.D.= 24.04). However, when analyzed each gender in particular, the
differences were only significant in group M-F.
(See Table 11 – Appendix D)
MCMI-II
MCMI-II
70
60
50
Mean
Mean
40
M1
30
M2
20
10
0
Psychotic Thinking
Major Depression
Delirious Disorder
***P≤
≤ .OO1
Graphic 11 – MCMI-II – Clinical Disorders – Severe Intensity
The clinical disorders scales – severe intensity, have shown the following
statistically significant differences on the following variables:
• Delirious Disorder T = 3.98*** ; M1 shows a higher average (M= 62.23; S.D.=
24.47) than M2 (M= 41.14; S.D.= 25.69). However, when analyzed each gender in
particular, the differences were only significant in the group F-M. (See Table 11 – Appendix D)
- 156 -
At the Risk Factor level (T =
2.11*), M1 shows a higher average (M= .41;
S.D.= .908) than M2 (M= .000; S.D.= .000). However, when analyzed each gender in
particular, the differences didn’t show significance for either group. (See Table 11 – Appendix
D)
We found variables with no significant differences in the total group (TG), but these
differences were detected in one particular group. In that case, in group F-M, significant
differences were observed in the variables antisocial (T= -2.17*) and compulsive (T= 2.79*). In the same way, in group M-F, significant differences were observed in the
variables desirableness (T= 5.89**), schizoid (T= 3.25*), phobic (T= 3.82*), dependent
(T= 2.93*), passive-aggressive (T= 3.65*), self-destructive (T= 9.03***), schizotypical (T=
3.68*), borderline (T= 3.00*), alcohol abuse (T= 5.30**), psychotic thinking (T= 2.58*)
and major depression (T= 5.14**). Within these variables, of MCMI-II scale, in which
significant differences between the two Moments were detected, M1 scores were higher in
all variables. (See Table 11 – Appendix D)
- 157 -
Descriptive statistics and intervals differences in MCMI-II scales
According to the Moment
Table 12 - Descriptive Statistics of the intervals of Scales, Validity Index and Risk Factor
of Millon Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
Valid
Questionable
20
2
90.9
9.1
21
1
95.5
4.5
< 35
35-75
> 75
5
12
5
22.7
54.5
22.7
9
12
1
40.9
54.5
4.5
< 35
35-75
> 75
1
12
9
4.5
54.5
40.9
1
13
8
4.5
59.1
36.4
< 35
35-75
> 75
14
6
2
63.6
27.3
9.1
15
7
0
68.2
31.8
.0
0
1
3
17
3
2
77.3
13.6
9.1
22
0
0
100.0
.0
.0
V – Validity
X – Sincerity
Y – Desirability
Z – Modification
Risk Factor
According to the intervals, as shown in Table 12, all the scales and validity indexes
of MCMI-II show a high frequency of values (equal or superior to 75), in group1. On the
other hand, in group2, a lower frequency of these values is shown. Group1 also exhibits a
suicide risk, whereas in group2, this one is absent in the whole sample.
Significant differences do exist in the proportion of cases “>75” in both Moments in
the variable sincerity, Z= 1.76*, but M1 shows a significant higher proportion (%=22.7)
- 158 -
than M2 (%=4.5). Significant differences also exist in the proportions of cases “0” in the
two moments in the variable risk factor, Z= -2.39**, but M1 shows a significant lower
proportion (%=77.3) than M2 (%=100.0).
Table 13 - Descriptive statistics of the intervals in personality Scales – Basics, Millon
Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
4
5
9
0
4
18.2
22.7
40.9
.0
18.2
4
10
8
0
0
18.2
45.5
36.4
.0
.0
< 35
35-59
60-74
75-84
≥ 85
7
5
5
3
2
31.8
22.7
22.7
13.6
9.1
7
11
2
0
2
31.8
50.0
9.1
.0
9.1
< 35
35-59
60-74
75-84
≥ 85
6
6
6
2
2
27.3
27.3
27.3
9.1
9.1
4
8
9
1
0
18.2
36.4
40.9
4.5
.0
< 35
35-59
60-74
75-84
≥ 85
3
8
6
4
1
13.6
36.4
27.3
18.2
4.5
3
6
7
4
2
13.6
27.3
31.8
18.2
9.1
< 35
35-59
60-74
75-84
≥ 85
2
5
5
3
7
9.1
22.7
22.7
13.6
31.8
1 – Schizoid
2 – Phobic
3 – Dependent
4 – Histrionic
5 – Narcissistic
2
9.1
6
27.3
6
27.3
1
4.5
7
31.8
(Table continues)
- 159 -
Table 13 (Cont)
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
2
9
5
3
3
9.1
40.9
22.7
13.6
13.6
1
6
10
2
3
4.5
27.3
45.5
9.1
13.6
< 35
35-59
60-74
75-84
≥ 85
2
13
3
3
1
9.1
59.1
13.6
13.6
4.5
2
9
6
1
4
9.1
40.9
27.3
4.5
18.2
< 35
35-59
60-74
75-84
≥ 85
1
3
9
1
8
4.5
13.6
40.9
4.5
36.4
0
5
9
5
3
.0
22.7
40.9
22.7
13.6
< 35
35-59
60-74
75-84
≥ 85
10
8
1
0
3
45.5
36.4
4.5
.0
13.6
12
5
2
0
3
54.5
22.7
9.1
.0
13.6
< 35
35-59
60-74
75-84
≥ 85
11
4
4
1
2
50.0
18.2
18.2
4.5
9.1
12
6
2
1
1
54.5
27.3
9.1
4.5
4.5
6A – Antisocial
6B – Aggressive-sadist
7 – Compulsive
8A – Passive-aggressive
8B – Self-destructive
According to the intervals, as shown in Table 13, all the personality scales – basics
of MCMI-II, show values above the “normality” threshold (equal or superiors to 75), in
group1. On the other hand, in group2, a lower frequency of values considered as
pathological was observed, except in the variables histrionic and aggressive-sadist,
- 160 -
exhibiting a higher percentage and, variable passive-aggressive, with the same results.
However, the majority of the sample, in group2, falls in normative thresholds.
Significant differences in the proportion of cases “>75” do exist in the two Moments
in variable schizoid, Z= 2.09*, but M1 shows a significantly higher proportion (%=18.2)
than M2 (%=.0).
Table 14 - Descriptive statistics of the intervals in personality Disorders Scales of the
Millon Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
4
7
7
0
4
18.2
31.8
31.8
.0
18.2
2
14
6
0
0
9.1
63.6
27.3
.0
.0
< 35
35-59
60-74
75-84
≥ 85
10
6
4
0
2
45.5
27.3
18.2
.0
9.1
7
10
5
0
0
31.8
45.5
22.7
.0
.0
< 35
35-59
60-74
75-84
≥ 85
3
5
9
2
3
13.6
22.7
40.9
9.1
13.6
8
2
10
2
0
36.4
9.1
45.5
9.1
.0
S – Schizotypical
C – Borderline
P – Paranoid
According to the intervals, as shown in Table 14, all personality disorders scales of
MCMI-II show values above the “normality” threshold (equal or superior to 75), in group1.
On the other hand, in group2, a lower frequency of values considered as pathological can
be observed, with the majority of the sample exhibiting values within the “normality” range.
- 161 -
Significant differences in the proportion of cases “>75” do exist in the two Moments
in the variable schizotypical, Z= 2.09*, but M1 shows a significant higher proportion
(%=18.2) than M2 (%=.0).
Significant differences in the proportion of cases “<35” also exist in the two
Moments in the variable paranoid, Z= -1.77*, but M1 shows a significant lower proportion
(%=13.6) than M2 (%=36.4).
Table 15 - Descriptive statistics of the intervals in Clinical Disorders Scales – Moderate
Intensity of the Millon Clinical Multiaxial Inventory (MCMI-II) according to the
Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
12
3
4
1
2
54.5
13.6
18.2
4.5
9.1
17
0
4
0
1
77.3
.0
18.2
.0
4.5
< 35
35-59
60-74
75-84
≥ 85
8
9
3
0
2
36.4
40.9
13.6
.0
9.1
10
9
3
0
0
45.5
40.9
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
4
8
8
1
1
18.2
36.4
36.4
4.5
4.5
3
13.6
10
45.5
8
36.4
1
4.5
0
.0
(Table continues)
A – Anxiety
H – Hysteriform
N – Hypomania
- 162 -
Table 15 (Cont)
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
12
3
3
1
3
54.5
13.6
13.6
4.5
13.6
20
0
0
1
1
90.9
.0
.0
4.5
4.5
< 35
35-59
60-74
75-84
≥ 85
14
5
2
0
1
63.6
22.7
9.1
.0
4.5
9
10
3
0
0
40.9
45.5
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
7
9
4
1
1
31.8
40.9
18.2
4.5
4.5
8
5
8
0
1
36.4
22.7
36.4
.0
4.5
D – Dysthymia
B – Alcohol Abuse
T – Drugs Abuse
According to the intervals, as shown in Table 15, all the clinical disorders scales –
moderate intensity of MCMI-II show values above the “normality” threshold (equal or
superior to 75), in group1. On the other hand, in group2, a lower frequency of values
considered as pathologic is shown.
Significant differences in the proportions of cases “<35” do exist in the two
Moments in the variable anxiety, Z= -1.67*, but M1 shows a significant lower proportion
(%=54.5) than M2 (%=77.3).
Significant differences in the proportions of cases “<35” also exist in the two
Moments in the variable dysthymia, Z= -2.17**, but M1 shows a significant lower
proportion (%=54.5) than M2 (%=90.9).
- 163 -
Significant differences in the proportion of cases “<35” can also be observed in the
two Moments in the variable Alcohol abuse, Z= -2.17**, but M1 shows a significant lower
proportion (%=54.5) than M2 (%=90.9).
Table 16 - Descriptive statistics of the intervals in Clinical Disorders Scales – Severe
Intensity of the Millon Clinical Multiaxial Inventory (MCMI-II) according to the
Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
8
5
7
0
2
36.4
22.7
31.8
.0
9.1
6
9
7
0
0
27.3
40.9
31.8
.0
.0
< 35
35-59
60-74
75-84
≥ 85
10
6
5
0
1
45.5
27.3
22.7
.0
4.5
6
13
3
0
0
27.3
59.1
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
2
6
9
1
4
9.1
27.3
40.9
4.5
18.2
8
6
8
0
0
36.4
27.3
36.4
.0
.0
SS – Psychotic Thinking
CC – Major Depression
PP – Delirious Disorder
According with the intervals, as shown in Table 16, all the clinical disorders scales –
severe intensity of MCMI-II show values above the “normality” threshold (equal or
superior to 75), in group1. On the other hand, in group2, a lower frequency of values
considered as pathologic is shown.
- 164 -
Significant differences in the proportion of cases “<35” do exist in the two Moments
in variable delirious disorder, Z= -2.16*, but M1 shows a significant lower proportion
(%=9.1) than M2 (%=36.4).
Regarding the remaining variables, in spite of the existence of differences in some
of the upper and/or lower indexes, it wasn’t possible to conclude that these differences are
significative due to the small number of individuals in this study.
The Minnesota Multiphasic Personality Inventory – 2 – MMPI- 2
The tests performed to evaluate the presence, or not, of significant differences
between Moments were parametric or not parametric, according to the statistic found in
Normality examinations (Kolmogorov-Smirnoff) and the Homoscedasticity (Homogeneity
of Variance) (Levene).
Differences in the scales of MMPI-2 according to the Moment
At the scales and validity index, statistically significant differences were found in
the following variables:
• Infrequency T= 4.19*** ; M1 shows a higher average (M= 54.95; S.D.= 12.27)
than M2 (M= 47.41; S.D.= 6.794). However, when analyzed each gender in particular,
those differences were only significant in the group F-M.
• Correction T= -2.69* ; M1 shows a lower average (M= 53.18; S.D.= 13.04) than
M2 (M= 59.77; S.D.= 11.46). However, when analyzed each gender in particular, those
differences were only significant in the group F-M.
- 165 -
• Back F T= 3.58** ; M1 shows a lower average (M= 53.42; D.P.= 11.95) than M2
(M= 47.18; D.P.= 6.974). However, when analyzed each gender in particular, those
differences were significant in both groups, F-M and M-F.
In the case of the variable insincerity, no significant differences were found in the
total group (TG) of individuals. However, when analyzed each gender in particular, those
differences proved to be significant in the group F-M.
In variable “Cannot Say”, no significant differences were found.
(See Table 17 – Appendix D)
MMPI-2
80
70
60
Mean
50
M1
40
M2
30
20
10
Hy
po
ch
on
dr
ia
s is
De
pr
es
sio
n
Ps
H
yc
ys
ho
te
ria
pa
t
h
M
i
cD
as
cu
ev
lin
ia
te
ity
/F
em
in
in
ity
Pa
ra
no
Ps
ia
yc
ha
st
he
ni
Sc
a
hi
zo
ph
re
ni
a
Hy
po
So
m
an
cia
ia
lI
nt
ro
ve
rs
io
n
0
**P≤
≤ .O1; **P≤
≤ .O1; *P≤
≤ .O5
Graphic 12 – MMPI-2 – Clinical Scales
At the clinical scales level and theirs subscales, statistically significant differences
were found in the following variables:
- 166 -
• Hysteria Hy1 T= -3.81**, M1 shows a lower average (M= 49.79; S.D.= 9.607)
than M2 (M= 57.20; S.D.= 7.878). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Hysteria Hy3 T= 2.43*, M1 shows a higher average (M= 53.37; S.D.= 14.44) than
M2 (M= 44.55; S.D.= 7.380). When analyzed each gender in particular, those differences
were only significant in the group M-F.
• Psychopathic Deviate Pd1 T= 4.03***, M1 shows a higher average (M= 56.63;
S.D.= 10.30) than M2 (M= 49.40; S.D.= 9.029). When analyzed each gender in particular,
those differences were only significant in the group F-M.
• Psychopathic Deviate Pd3 T= -4.71***, M1 shows a lower average lower (M=
50.00; S.D.= 8.988) than M2 (M= 58.10; S.D.= 8.233). When analyzed each gender in
particular, those differences were significant in both groups, F-M and M-F.
• Psychopathic Deviate Pd4 T= 3.13**, M1 shows a higher average (M= 53.47;
S.D.= 11.70) than M2 (M= 47.55; S.D.= 8.476). When analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F.
• Psychopathic Deviate Pd5 T= 2.28*, M1 shows a higher (M= 49.37; S.D.= 12.00)
than M2 (M= 43.75; S.D.= 8.589). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Masculinity/Femininity T= 5.99***, M1 shows a higher average higher (M=
69.68; S.D.= 11.12) than M2 (M= 48.86; S.D.= 6.483). When analyzed each gender in
particular, those differences were significant in both groups, F-M and M-F.
- 167 -
• Paranoia Pa1 T= 2.24*, M1 shows a higher average (M= 56.16; S.D.= 12.42) than
M2 (M= 50.40; S.D.= 11.06). When analyzed each gender in particular, those differences
weren’t significant in either groups.
• Paranoia Pa2 T= 2.80*, M1 shows a higher average (M= 51.95; S.D.= 12.43) than
M2 (M= 44.85; S.D.= 9.264). When analyzed each gender in particular, those differences
were only significant in the group M-F.
• Schizophrenia T= 3.60**, M1 shows a higher average (M= 58.95; S.D.= 15.59)
than M2 (M= 48.10; S.D.= 6.696). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Schizophrenia Sc1 T= 6.08***, M1 shows a higher average (M= 58.16; S.D.=
12.45) than M2 (M= 45.90; S.D.= 7.137). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Schizophrenia Sc2 T= 3.17**, M1 shows a higher average (M= 55.21; S.D.=
11.45) than M2 (M= 45.20; S.D.= 9.059). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Schizophrenia Sc4 T= 2.49*, M1 shows a higher average (M= 49.32; S.D.= 11.93)
than M2 (M= 42.75; S.D.= 6.874). When analyzed each gender in particular, those
differences weren’t significant in either groups.
• Social Introversion T= 5.40***, M1 shows a higher average (M= 54.14; S.D.=
12.25) than M2 (M= 41.60; S.D.=8.081). When analyzed each gender in particular, those
differences were significant in both groups, F-M and M-F.
- 168 -
• Social Introversion Si1 T= 3.71**, M1 shows a higher average (M= 50.16; S.D.=
10.64) than M2 (M= 43.65; S.D.=7.492). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Social Introversion Si2 T= 4.09***, M1 shows a higher average (M= 58.21; S.D.=
12.90) than M2 (M= 46.90; S.D.=6.103). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Social Introversion Si3 T= 2.39*, M1 shows a higher average (M= 48.47; S.D.=
11.60) than M2 (M= 42.00; S.D.=8.322). When analyzed each gender in particular, those
differences weren’t significant in either groups.
In the variable hypomania Ma2 no differences were found in the total group (TG) of
individuals. However, when analyzed each gender in particular, those differences were
significant in the group F-M.
In the case of variables depression, depression D1, depression D5, hysteria Hy4 and
psychasthenia, no significant differences in total group (TG) of the individuals were found.
However, when analyzed each gender in particular, those differences were significant in the
group M-F.
The remaining variables didn’t exhibit any significant differences between the two
moments.
(See Table 18 – Appendix D)
- 169 -
MMPI-2
MMPI-2
70
60
Mean
M é d ia
50
40
M1
M2
30
20
10
S
S
AA
AP
DS
M
PS
Pk
GP
GB
t
M
Re
Do
OH
M
AC
-R
ES
R
A
0
Graphic 13 – MMPI-2 – Supplementary and Additionals Scales
**P≤
≤ .O1; **P≤
≤ .O1; *P≤
≤ .O5
In which supplementary and additional scales are concerned, statistically significant
statistics differences were found in the following variables:
• Anxiety - A T= 3.30**, M1 shows a higher average (M= 49.21; S.D.= 10.80) than
M2 (M= 42.05; S.D.=6.848). When analyzed each gender in particular, those differences
were significant in both groups, F-M and M-F.
• Dominance - Do T= -2.24*, M1 shows a lower average (M= 47.26; S.D.= 10.48)
than M2 (M= 52.50; S.D.= 8.829). When analyzed each gender in particular, those
differences weren’t significant in either groups.
- 170 -
• Social Responsibility - Re T= -2.81*, M1 shows a lower average (M= 49.11;
S.D.= 10.41) than M2 (M= 55.95; S.D.= 9.611). When analyzed each gender in particular,
those differences were only significant in the group F-M.
• Feminine Gender Role – GF T= -3.58**, M1 shows a lower average (M= 39.68;
S.D.= 20.13) than M2 (M= 55.95; S.D.= 9.611). When analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F.
• Biological Gender Role - GB T= -13.5***, M1 shows a lower average (M= 31.26;
S.D.= 8.530) than M2 (M= 57.32; S.D.= 9.858). When analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F, and strongly negative.
• Psychological Gender Role - GP T= 4.61***, M1 shows a higher average (M=
62.58; S.D.= 10.77) than M2 (M= 54.55; S.D.= 7.939). When analyzed each gender in
particular, those differences were significant in both groups, F-M and M-F, and strongly
positive.
• Post-traumatic Stress Disorder Scale - PK T= 3.16**, M1 shows a higher average
(M= 52.79; S.D.= 13.82) than M2 (M= 44.50; S.D.= 7.323). When analyzed each gender in
particular, those differences were significant in both groups, F-M and M-F, and strongly
positive.
• Post-traumatic Stress Disorder Scale - PS T= 4.26***, M1 shows a higher average
(M= 51.16; S.D.= 12.14) than M2 (M= 44.05; S.D.= 7.015). When analyzed each gender in
particular, those differences were significant in both groups, F-M and M-F, and strongly
positive.
- 171 -
• Marital Distress - MDS T= 3.32**, M1 shows a higher average (M= 54.00; S.D.=
10.85) than M2 (M= 47.45; S.D.= 7.944). When analyzed each gender in particular, those
differences were only significant in the group F-M.
The variable male gender role didn’t exhibit significative differences in the total
group (TG) of individuals. However, when analyzed each gender in particular, those
differences were significant in both groups, F-M (strongly positive) and M-F (strongly
negative).
In the variables Ego strength - Es, MacAndrew alcoholism - MAC-R and College
Maladjustment – Mt, no significant differences were found in the total group (GT) of
individuals. However, when analyzed each gender in particular, those differences were
significant in the group M-F.
No significant differences were found in the remaining variables between the two
Moments.
(See Table 18 – Appendix D)
- 172 -
MMPI-2
MMPI-2
60
50
40
M éd ia
Mean
M1
M2
30
20
10
Graphic 14 – MMPI-2 – Content Scales
R
TR
RK
W
M
FA
D
SO
E
LS
A
TP
P
AS
CY
N
G
AN
Z
BI
P
A
HE
DE
OB
S
S
FR
AN
X
0
**P≤
≤ .O1; **P≤
≤ .O1; *P≤
≤ .O5
Regarding the content scales, statistically significant differences were found in the
following variables:
• Anxiety - ANX T= 2.28*, M1 shows a higher average (M= 51.74; S.D.= 13.51)
than M2 (M= 45.15; S.D.= 7.184). When analyzed each gender in particular, those
differences were only significant in the group M-F.
• Depression - DEP T= 3.54**, M1 shows a higher average (M= 52.89; S.D.=
14.10) than M2 (M= 42.85; S.D.= 6.319). When analyzed each gender in particular, those
differences were significant in both groups, F-M and M-F.
• Cynicism - CYN T= 2.26*, M1 showed a higher average (M= 52.21; S.D.=
12.74) than M2 (M= 47.20; S.D.= 11.80). When analyzed each gender in particular, those
differences were only significant in the group F-M.
- 173 -
• Low Self-Esteem - LSE T= 3.48**, M1 shows a higher average (M= 46.00; S.D.=
9.71) than M2 (M= 40.80; S.D.= 8.377). When analyzed each gender in particular, those
differences were only significant in the group F-M.
• Social Discomfort - SOD T= 4.50***, M1 shows a higher average (M= 53.26;
S.D.= 11.31) than M2 (M= 44.45; S.D.= 6.194). When analyzed each gender in particular,
those differences were significant in both groups, F-M and M-F.
• Family Problems - FAM T= 2.71*, M1 shows a higher average (M= 54.00; S.D.=
12.05) than M2 (M= 48.60; S.D.= 9.616). When analyzed each gender in particular, those
differences weren’t significant in either group.
• Negative Treatment Indicators - TRT T= 2.59*, M1 shows a higher average (M=
48.37; S.D.= 9.610) than M2 (M= 43.20; S.D.= 5.569). When analyzed each gender in
particular, those differences weren’t significant in either group.
The variable obsessiveness didn’t show significant differences in the total group
(TG) of individuals. However, when analyzed each gender in particular, those differences
were significant in the group F-M.
In the case of the variable fears, no significant differences in the total group (TG) of
individuals were observed. However, when analyzed each gender in particular, these
differences were significant in the group M-F.
The remaining variables didn’t exhibit significant differences between the two
Moments.
(See Table 20 – Appendix D)
- 174 -
Descriptive statistics and differences in intervals of scales of MMPI-2
according to the Moment
Table 21 - Descriptive statistics of the intervals in Validity and Inconsistency Scales of
the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the
Moment
Moment 1
Moment 2
N
%
N
%
< 50
50-59
60-69
70-79
≥ 80
5
6
7
3
1
22.7
27.3
31.8
13.6
4.5
4
9
4
4
1
18.2
40.9
18.2
18.2
4.5
< 50
50-59
60-64
65-79
80-100
8
7
4
1
2
36.4
31.8
18.2
4.5
9.1
14
8
0
0
0
63.6
36.4
.0
.0
.0
< 50
50-59
60-70
> 70
10
5
4
3
45.5
22.7
18.2
13.6
4
5
11
2
18.2
22.7
50.0
9.1
< 50
50-64
65-79
80-100
>100
9
6
4
0
0
40.9
27.3
18.2
.0
.0
18
3
1
0
0
81.8
13.6
4.5
.0
.0
22
100.0
22
100.0
22
100.0
22
100.0
L – Lie
F – Infrequency
K – Correction
Fb – Back F
TRIN – True Response Inconsistency
< 14 (Valid)
VRIN – Variable Response Inconsistency
≤ 14 (Valid)
- 175 -
According to the intervals of the scales TRIN and VRIN, as shown on Table 21, the
whole sample, in both M1 and in M2, (%= 100.0) show the profile validity. All validity
scales of MMPI-2 exhibit a frequency of high values, in group1. On the other hand, a lower
frequency of these values is observed in group2.
Significant differences in the proportion of “<50” do exist in the two moments in
the variable infrequency, Z= -1.80*, but M1 shows a significant lower proportion (%=
36.4) than M2 (%= 63.6).
Significant differences in the proportions of “<50” do also exist in the two moments
in the variable correction, Z= 1.94*, but M1 shows a significant higher proportion (%=
45.5) than M2 (%= 18.2).
Significant differences in the proportion of “<50” are also found in the two
moments in the variable Back F, Z= -2.79**, but M1 shows a significant lower proportion
(%= 40.9) than M2 (%= 81.8).
- 176 -
Table 22 - Descriptive statistics of the intervals in Clinical Scales of the Minnesota
Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 40
40-59
60-80
> 80
4
14
4
0
18.2
63.6
18.2
.0
1
17
2
0
4.5
77.3
9.1
.0
< 40
40-59
60-70
> 70
4
11
5
2
18.2
50.0
22.7
9.1
4
12
3
1
18.2
54.5
13.6
4.5
< 40
40-59
60-80
> 80
2
12
8
0
9.1
54.5
36.4
.0
3
15
2
0
13.6
68.2
9.1
.0
< 40
40-59
60-75
> 75
0
11
10
1
.0
50.0
45.5
4.5
2
14
4
0
9.1
63.6
18.2
.0
< 40
40-59
60-75
> 75
0
3
12
7
.0
13.6
54.5
31.8
4
17
1
0
18.2
77.3
4.5
.0
< 35
35-44
45-49
50-59
60-70
> 70
2
2
3
8
5
2
9.1
9.1
13.6
36.4
22.7
9.1
1
4.5
6
27.3
4
18.2
5
22.7
4
18.2
0
.0
(Table continues)
Hs – Hypochondriasis
D – Depression
Hy – Hysteria
Pd – Psychopathic Deviate
Mf – Masculinity – Femininity
Pa – Paranoia
- 177 -
Table 22 (Cont)
Moment 1
Moment 2
N
%
N
%
< 40
40-59
60-75
> 75
5
9
6
2
22.7
40.9
27.3
9.1
4
16
0
0
18.2
72.7
.0
.0
< 40
40-59
60-75
> 75
2
10
8
2
9.1
45.5
36.4
9.1
1
18
1
0
4.5
81.8
4.5
.0
< 40
40-59
60-69
70-80
> 80
2
17
2
1
0
9.1
77.3
9.1
4.5
.0
5
11
4
0
0
22.7
50.0
18.2
.0
.0
< 40
40-59
60-75
> 75
2
13
5
2
9.1
59.1
22.7
9.1
9
10
1
0
40.9
45.5
4.5
.0
Pt – Psychasthenia
Sc – Schizophrenia
Ma – Hypomania
Si – Social Introversion
According to the intervals, as shown in Table 22, all the clinical scales of MMPI-2
exhibit values above the “normality” threshold (equal or superior to 60), in group1. On the
other hand, in group2, a lower frequency of values considered as pathologic were found,
whose values fall into the normality range in the majority of the sample.
Significant differences in the proportion of “>60” in the two Moments do exist in
the variable hysteria, Z= 2.16*, but M1 shows a significant higher proportion (%= 36.4)
than M2 (%= 9.1).
- 178 -
Significant differences in the proportion of “>60” in the two Moments do also exist
in the variable psychopathic Deviate, Z= 2.22*, but M1 shows a significant higher
proportion (%= 50.0) than M2 (%= 18.2).
Significant differences in the proportion of “<40” in the two Moments are also seen
in the variable masculinity-femininity, Z= -2.10*, but M1 shows a significant lower
proportion (%= .0) than M2 (%= 18.2).
We could also find significant differences in the proportion of “>60” in the two
Moments in the variable masculinity-femininity, Z= 5.45***, but M1 exhibits a significant
higher proportion (%= 86.3) than M2 (%= 4.5).
Significant differences in the proportion of “>60” in the two Moments for the
variable psychasthenia were also detected, Z= 3.13***, but M1 shows a significant higher
proportion (%= 36.4) than M2 (%= .0).
Significant differences in the proportion of “>60” in the two Moments in the
variable schizophrenia, Z= 3.14***, but M1 shows a significant higher proportion (%=
45.5) than M2 (%= 4.5).
Finally, significant differences in the proportion of “<40” in the two Moments in
variable social introversion were found, Z= -2.44**, but M1 shows a significant lower
proportion (%= 9.1) than M2 (%= 40.9).
- 179 -
Table 23 - Descriptive statistics of the intervals of Supplementary and Additional Scales
of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the
Moment
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
6
11
2
27.3
50.0
9.1
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
3
14
2
13.6
63.6
9.1
2
15
3
9.1
68.2
13.6
< 40
40-65
> 65
3
14
2
13.6
63.6
9.1
0
20
0
.0
90.9
.0
< 50
50-64
≥ 65
11
7
1
50.0
31.8
4.5
11
5
4
50.0
22.7
18.2
< 40
40-65
> 65
1
16
2
4.5
72.7
9.1
1
14
5
4.5
63.6
22.7
< 40
40-65
> 65
6
13
0
27.3
59.1
.0
1
17
2
4.5
77.3
9.1
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
1
17
2
4.5
77.3
9.1
< 40
40-65
> 65
5
11
3
22.7
50.0
13.6
7
13
0
31.8
59.1
.0
< 40
40-65
> 65
16
3
0
72.7
13.6
.0
2
9.1
16
72.7
4
18.2
(Table continues)
A – Anxiety
R – Repression
Es – Ego Strength
MAC-R – MacAndrew-Revised
O-H – Overcontrolled Hostility
Do – Dominance
Re – Social Responsibility
Mt – College Maladjustment
GB – Biologic Gender Role1
- 180 -
Table 23 (Cont)
Moment 1
GB – Psychological Gender Role
Moment 2
N
%
N
%
< 40
40-65
> 65
0
13
6
.0
59.1
27.3
0
19
3
.0
86.4
13.6
< 40
40-65
> 65
6
9
4
27.3
40.9
18.2
8
12
0
36.4
54.5
.0
< 40
40-65
> 65
5
12
2
22.7
54.5
9.1
10
10
0
45.5
45.5
.0
< 40
40-65
> 65
1
14
4
4.5
63.6
18.2
4
16
0
18.2
72.7
.0
< 40
40-65
> 65
4
15
0
18.2
68.2
.0
6
14
0
27.3
63.6
.0
< 40
40-65
> 65
6
10
3
27.3
45.5
13.6
5
13
2
22.7
59.1
9.1
1
PK – Posttraumatic Stress Disorder
PS– Posttraumatic Stress Disorder
MDS – Marital Distress
APS – Addiction Potential
AAS – Addiction Admission
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was
performed in accordance to the Psychological Sex.
According to the intervals, as shown on Table 23, the supplementary and additional
scales show a higher frequency of high values (superior to 65), in both group1 and group2.
However, these results go together with the differentiation of variables, and in the majority
of the sample, these values fall within the range of standard threshold.
- 181 -
Significant differences were found in the proportion of “<40” in the two Moments
in the variable dominance, Z= 2.07*, but M1 shows a significant higher proportion (%=
27.3) than M2 (%= 4.5).
Significant differences in the proportion of “>65” were also detected in the two
Moments in the variable posttraumatic stress disorder PK, Z= 2.10*, but M1 shows a
significant higher proportion (%= 18.2) than M2 (%= .0).
Significant differences in the proportion of “<40” in the two Moments in the
variable posttraumatic stress disorder PS, Z= -1.65* was found, but M1 shows a significant
lower proportion (%= 22.7) than M2 (%= 45.5).
Significant differences in the proportion of “>65” in the two Moments in variable
marital distress, Z= 2.10* could also be found, but M1 shows a significant higher
proportion (%= 18.2) than M2 (%= .0).
Significant differences in the proportion of “<40” in the two Moments in variable
biological gender role, Z= 4.30*** was found, but M1 shows a significant higher
proportion (%= 72.9) than M2 (%= 9.1).
Significant differences in the proportion of “>65” in the two Moments in variable
biological gender role, Z= -2.09* was also detected, but M1 shows a significant lower
proportion (%= .0) than M2 (%= 18.2).
- 182 -
Table 24 - Descriptive statistics of the intervals of Content Scales of the Minnesota
Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
5
10
4
22.7
45.5
18.2
4
18
0
18.2
72.7
.0
< 40
40-65
> 65
8
10
1
36.4
45.5
4.5
5
15
0
22.7
68.2
.0
< 40
40-65
> 65
7
11
1
31.8
50.0
4.5
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
4
11
4
18.2
50.0
18.2
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
5
12
2
22.7
54.5
9.1
2
18
0
9.1
81.8
.0
< 40
40-65
> 65
4
15
0
18.2
68.2
.0
4
16
0
18.2
72.7
.0
< 40
40-65
> 65
8
10
1
36.4
45.5
4.5
10
9
1
45.5
40.9
4.5
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
7
13
0
31.8
59.1
.0
< 40
40-65
> 65
5
13
1
22.7
59.1
4.5
8
36.4
11
50.0
1
4.5
(Table continues)
ANX – Anxiety
FRS – Fears
OBS – Obsessiveness
DEP – Depression
HEA – Health Concerns
BIZ – Bizarre Mentation
ANG – Anger
CYN – Cynicism
ASP – Antisocial Practices
- 183 -
Table 24 (Cont)
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
10
7
2
45.5
31.8
9.1
8
11
1
36.4
50.0
4.5
< 40
40-65
> 65
6
12
1
27.3
54.5
4.5
13
7
0
59.1
31.8
.0
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
8
12
0
36.4
54.5
.0
< 40
40-65
> 65
3
13
3
13.6
59.1
13.6
6
14
0
27.3
63.6
.0
< 40
40-65
> 65
8
9
2
36.4
40.9
9.1
5
15
0
22.7
68.2
.0
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
7
13
0
31.8
59.1
.0
TPA – Type A
LSE – Low Self-Esteem
SOD – Social Discomfort
FAM – Family Problems
WRK – Work Interference
TRR – Negative Treatment Indicators
According to the intervals, as shown on Table 24, the content scales of MMPI-2
show a higher frequency of high results (superior to 65), in group1. On the other hand, in
group2, we could find a lower frequency of values considered as pathologic, and the
majority of the sample exhibited standardized values.
Significant differences in the proportion of “>65” do exist in the two Moments in
variable Anxiety, Z= 2.10*, but M1 shows a significant higher proportion (%= 18.2) than
M2 (%= .0).
- 184 -
Significant differences also exist in the proportion of “<40” in the two Moments in
variable Depression, Z= -1.65*, but M1 shows a significant lower proportion (%= 18.2)
than M2 (%= 40.9).
Significant differences in the proportion of “>65” do also exist in the two Moments
in variable Depression, Z= 2.10*, but M1 shows a significant higher proportion (%= 18.2)
than M2 (%= .0).
Significant differences in the proportion of “<40” are also found in the two
Moments in variable Low Self-Esteem, Z= -2.12*, but M1 shows a significant lower
proportion (%= 27.3) than M2 (%=59.1).
In the remaining variables, in spite of some differences in some proportions on the
upper and lower indexes, we could not determine whether these were significative
differences or not, due to the small number of individuals in this study.
Correlation Matrix
Correlation matrix in different scales in Moment 1
In M1, a positive association, moderate and significative was found, between the
following pairs of variables:
• Interpersonal Sensivity and BDI (R= .52*); employment (R= .65**); social
activities and leisure time (R= .56**); social adaptation (R= .43*); social
introvertion (R= .50*); low self-esteem (R= .51*); professional interference
(R= .50*).
- 185 -
• BDI and employment (R= .53*); extended family (R= .59*); social adaptation
(R= .70***); social introvertion (R= .61**); social discomfort (R= .51*); treatment
negative indicators (R= .51*).
• Employment and social activities and leisure time (R= .61*); social introvertion
(R= .57*); low self-esteem (R= .63*); social discomfort (R= .68*).
• Domestics Tasks and social activities and leisure time (R= .44*); extended family
(R= .61*); social adaptation (R= .67***); social discomfort (R= .52*).
• Social Activities and Leisure Time and extended family (R= .61**); social
introvertion (R= .65***); low self-esteem (R= .68***); social discomfort (R= .57*);
treatment negative indicators (R= .72***).
• Extended Family and social introvertion (R= .44*).
• Relationship with the Spouse and social introvertion (R= .69*).
• Social Adaptation and social introvertion (R= .69***); low self-esteem
(R= .63**); social discomfort (R= .66**); professional interference (R= .56**);
treatment negative indicators (R= .66**).
• Social Introvertion and low self-esteem (R= .63**); professional interference
(R= .63**).
• Social Responsibility and psychological gender role (R= .49*)
In M1, a positive association, strong and significative was also found, between the
following pairs of variables:
• BDI and social activities and leisure time (R= .76***).
- 186 -
• Social Adaptation and employment (R= .76***); extended family (R= .78***);
relationship with the spouse (R= .81***).
In M1, a positive association, very strong and significative between the following
pairs of variables was detected:
• Nuclear Family and employment (R= .98***); relationship with the spouse
(R= .85***); social adaptation (R= .85***); masculinity/femininity (R= .85***);
antisocial behaviors (R= .99***); low self-esteem (R= .98***); professional
interference (R= .93***).
• Social Activities and Leisure Time and social adaptation (R= .88***)
• Social Introvertion and social discomfort (R= .89***)
• Low Self-Esteem and professional interference (R= .85***); treatment negative
indicators (R= .85***)
• Professional Interference and treatment negative indicators (R= .84***)
In M1, a negative association, moderate and signficative between the following
pairs of variables was found:
• Biological Gender Role and BDI (R= -.52*); employment (R= -.62*); domestics
tasks (R= -.74***); social activities and leisure time (R= -.63**); extended family
(R= -.49*); relationship with the spouse (R= -.66*); social adaptation (R= -.74***);
low self-esteem (R= -.52*); social discomfort (R= -.50*); treatment negative
indicators (R= -.46*).
- 187 -
• Social Responsibility and antisocial behaviors (R= -.52*); low self-esteem (R= .53*); professional interference (R= -.61**); treatment negative indicators (R= .46*).
(See Table 25 – Appendix D)
Correlations matrix in different scales in Moment 2
In M2, a positive, moderate and significative association between these pairs of
variables was found:
• BDI and interpersonal sensitivity (R= .45*); domestics tasks (R= .48*); antisocial
behaviors (R= .52**).
• Employment and social adaptation (R= .64**).
• Domestics Tasks and extended family (R= .45*); social adaptation (R= .66**);
negative treatment indicators (R= .49*).
• Social Activities and Leisure Time and extended family (R= .54*); social
adaptation (R= .61**); social discomfort (R= .49*).
• Extended Family and low self-esteem (R= .50*); negative treatment indicators
(R= .64**).
• Relationship with the Spouse and antisocial practices (R= .62**); work
interference (R= .62**).
• Social Adaptation and low self-esteem (R= .54*); social discomfort (R= .46*);
negative treatment indicators (R= .66**).
• Social Introvertion and low self-esteem (R= .61**); social discomfort (R= .58**).
- 188 -
• Social Responsibility and biological gender role (R= .60**); psychological gender
role (R= .44*); PRS duration (R= .57*).
• Antisocial Practices and low self-esteem (R= .55*); work interference
(R= .67***); negative treatment indicators (R= .56**).
• Low Self-Esteem and social discomfort (R= .57**); work interference
(R= .70***); negative treatment indicators (R = .59**).
• Masculinity-femininity and PRS duration (R= .56*).
In M2, a positive, strong and significative association between those pairs of
variables was detected:
• Children and psychological gender role (R= .79*); low self-esteem (R= .79*);
social discomfort (R= .83*).
• Professional Interference and negative treatment indicators (R= .77***).
In M2, a positive, very strong and significative association between the following
pairs of variables was found:
• Children and social introvertion (R= .91**).
• Extended Family and social adaptation (R= .85***).
- 189 -
In M2, a negative, moderate and significative association between these pairs of
variables was detected:
• Biological Gender Role and BDI (R= -.51*); extended family (R= -.62**); social
adaptation (R= -.51*); antisocial practices (R= -.63**); low self-esteem (R= .69***); work interference (R= -.60**); negative treatment indicators (R= -.54**).
• Relationship with the Spouse and masculinity-femininity (R= -.65*).
• PRS Duration and antisocial practices (R= -.61*); BDI (R= -.59*).
In M2, a negative, strong and significative association between the following pairs
of variables was found:
• Social Activities and Leisure Time and nuclear family (R= -.80*).
• Social Responsibility and antisocial practices (R= -.82***)
(See Table 26 – Appendix D)
Correlation Matrix in different scales according to the Moment
A positive, moderate and significative association between these pairs of variables,
in the two Moments was found:
• Interpersonal Sensivity (M1) and social introvertion (M2) (R= .54*); work
interference (M2) (R= .48*).
• BDI (M1) and employment (M2) (R= .48*); extended family (M2) (R= .45*);
social adaptation (M2) (R= .53*); low self-esteem (M2) (R= .47*).
• Employment (M1) and employment (M2) (R= .48*); social adaptation (M2)
(R= .52*); social introvertion (M2) (R= .51*).
- 190 -
• Domestics Tasks (M1) and domestics tasks (M2) (R= .52*); extended family (M2)
(R= .61**); social adaptation (M2) (R= .58**); work interference (M2) (R= .45*);
negative treatment indicators (M2) (R= .65**).
• Social Activities and Leisure Time (M1) and BDI (M 2) (R= .50*); domestics
tasks (M2) (R= .59**); extended family (M2) (R= .55**); social adaptation (M2)
(R= .62**); low self-esteem (M2) (R= .59**); work interference (M2) (R= .66**);
negative treatment indicators (M2) (R= .74***).
• Extended Family (M1) and BDI (M2) (R= .46*); domestics tasks (M2) (R= .51*);
extended family (M2) (R= .59**); social adaptation (M2) (R= .53*); negative
treatment indicators (M2) (R= .53*).
• Relationship with the Spouse (M1) and social introvertion (M2) (R= .65*); low
self-esteem (M2) (R= .69*); social discomfort (M) (R= .67*).
• Social Adaptation (M1) and BDI (M2) (R= .48*); domestics tasks (M2)
(R= .55**); extended family (M2) (R= .67***); social adaptation (M2) (R= .70***);
low self-esteem (M2) (R= .68***); social discomfort (M2) (R= .49*); work
interference (M2) (R= .64**); negative treatment indicators (M2) (R= .69***).
• Social Introvertion (M1) and social introvertion (M2) (R= .62**); social
discomfort (M2) (R= .61**); professional interference (M2) (R= .52*).
• Social Responsibility (M1) and social responsibility (M2) (R= .60*); biological
gender role (M2) (R= .51*).
• Biological Gender Role (M1) and biological gender role (M2) (R= .56*)
• Psychological Gender Role (M1) and psychological gender role (M2) (R= .62**).
- 191 -
• Low Self-esteem (M1) and antisocial practices (M2) (R= .60**); low self-esteem
(M2) (R= .74***); workl interference (M2) (R= .57*); negative treatment indicators
(M2) (R= .61**).
• Social Discomfort (M1) and social discomfort (M2) (R= .70**).
• Work Interference (M1) and low self-esteem (M2) (R= .64**); work interference
(M2) (R= .66**); negative treatment indicators (M2) (R= .60*).
• Negative Treatment Indicators (M1) and social adaptation (M2) (R= .52*);
antisocial practices (M2) (R= .66**).
A positive association, strong and significative association between the following
pairs of variables, in the two Moments was detected:
• Social Responsibility (M1) and nuclear family (M2) (R= .78*).
• Social Introvertion (M1) and low self-esteem (M2) (R= .78***).
• Antisocial Practices (M1) and antisocial behaviors (M2) (R= .78***).
• Work Interference (M1) and antisocial practices (M2) (R= .83***).
• Negative Treatment Indicators (M1) and low self-esteem (M2) (R= .78***); work
interference (M2) (R= .78***); negative treatment indicators (M2) (R= .81***).
A positive, very strong and significative association between these pairs of variables,
in the two Moments was found:
• Interpersonal Sensivity (M1) and children (M2) (R= .94**).
• BDI (M1) and children (M2) (R= .87*).
• Social Activities and Leisure Time (M1) and children (M. 2) (R= .76*).
- 192 -
• Social Adaptation (M1) and children (M2) (R= .81*).
• Masculinity – femininity (M1) and children (M2) (R= .78**).
• Social Introvertion (M1) and children (M2) (R= .96***).
• Social Discomfort (M1) and children (M2) (R= .89*).
• Nuclear Family (M1) and interpersonal sensivity (M2) (R= .88*); BDI (M2)
(R= .92**); social adaptation (M2) (R= .93**); antisocial practices (M2) (R= .85*);
low self-esteem (M2) (R= .91*).
A negative, moderate and significative association between pairs of variables, in the
two Moments was found:
• Social Activities and Leisure Time (M1) and biological gender role (M2) (R= .52*).
• Social Adaptation (M1) and biological gender role (M2) (R= -.57**).
• Antisocial Practicess (M1) and biological gender role (M2) (R= -.49*);
masculinity-femininity (M2) (R= -.48*).
• Low Self-esteem (M1) and biological gender role (M2) (R= -.62**); social
responsibility (M2) (R= -.54*).
• Work Interference (M1) and biological gender role (M2) (R= -.52*); social
responsibility (M2) (R= -.69**).
• Negative Treatment Indicators (M1) and biological gender role (M2) (R= -.61**);
social responsibility (M2) (R= -.54*).
• Masculinity-femininity (M1) and masculinity-femininity(M2) (R= -.70***).
- 193 -
• Social Responsibility (M1) and antisocial behaviors (M2) (R= -.65**); low selfesteem (M2) (R= -.53*); workl interference (M2) (R= -.62**).
• Biological Gender Role (M1) and social adaptation (M2) (R= -.71***); low selfesteem (M2) (R= -.60*); work interference (M2) (R= -.60**); negative treatment
indicators (M2) (R= -.53*).
A negative, strong/very strong and significative association between the following
pairs of variables, in the two Moments was detected:
• Nuclear Family (M1) and masculinity-femininity (M2) (R= -.88*); biological
gender role (M2) (R= -.97***).
• Antisocial Practices (M1) and social responsibility (M2) (R= -.75***).
(See Table 27 – Appendix D)
Gender Differences
Differences in the various scales according to gender in Moment 1
The tests performed to investigate the presence, or not, of significant differences
between Moments were parametric or not parametric, according to the statistics found in
Normality examinations (Kolmogorov-Smirnoff) and the Homoscedasticity (Homogeneity
of Variance) (Levene).
At SCL-90 level, statistically significant differences were found in the following
variables:
• Somatization
T= -2.60*, F-M gender shows a lower average (M= .490;
S.D.= .476) than M-F gender (M= 1.235; S.D.= .869).
- 194 -
• Obsession-Compulsion T= -2.50*, F-M gender shows a lower average (M= .731;
S.D.= .604) than M-F gender (M= 1.583; S.D.= .966).
• Depressivity
T= -2.10*, F-M gender shows a lower average (M= .770;
S.D.= .757) than M-F gender (M= 1.623; S.D.= 1.078).
• Paranoid Ideation T= -2.21*, F-M gender shows a lower average (M= .800;
S.D.= .700) than M-F gender (M= 1.643; S.D.= 1.036).
• Psychoticism
T= -2.92**,F-M gender shows a lower average (M= .456;
S.D.= .475) than M-F gender (M= 1.333; S.D.= .948).
• Death Thoughts T= -2.26*, F-M gender shows a lower average (M= 1.13; S.D.=
1.025) than M-F gender (M= 2.17; S.D.= .753).
• General Symptoms Index
T= -2.61*, F-M gender shows a lower average
(M= .639; S.D.= .491) than M-F gender (M= 1.440; S.D.= .959).
Regarding MCMI-II, the following statistically significant differences were found in
variables:
• Sincerity T= -2.50*, F-M gender shows a lower average (M= 49.38; S.D.= 20.48)
than the M-F gender (M= 72.67; S.D.= 15.96).
• Desirability T= -3.74***, F-M gender shows a lower average (M= 25.94; S.D.=
21.08) than M-F gender (M= 63.33; S.D.= 26.56).
• Phobic T= -2.90*, F-M gender shows a lower average (M= 40.38; S.D.= 28.10)
than M-F gender (M= 79.00; S.D.= 26.86).
• Dependent T= -3.26**, F-M gender shows a lower average (M= 38.50; S.D.=
25.52) than M-F gender (M= 77.00; S.D.= 21.96).
- 195 -
• Compulsive T= 2.55*, F-M gender shows a higher average (M= 81.81; S.D.=
21.56) than M-F gender (M= 55.50; S.D.= 21.63).
• Passive-aggressive T= -3.47**, F-M gender shows a lower average (M= 26.19;
S.D.= 23.80) than M-F gender (M= 69.00; S.D.= 31.02).
• Self-destructive T= -4.69***, F-M gender shows a lower average (M= 24.44;
S.D.= 23.86) than M-F gender (M= 77.17; S.D.= 22.27).
• Schizotypical T= -2.45*, F-M gender shows a lower average (M= 48.50; S.D.=
26.72) than M-F gender (M= 78.17; S.D.= 20.27).
• Borderline T= -3.78***, F-M gender shows a lower average (M= 30.81; S.D.=
23.75) than M-F gender (M= 70.67; S.D.= 15.82).
• Hysteriform T= -2.48*, F-M gender shows a lower average (M= 39.38; S.D.=
21.36) than M-F gender (M= 62.33; S.D.= 11.43).
• Hypomania T= -2.12*, F-M gender shows a lower average (M= 48.56; S.D.=
22.07) than M-F gender (M= 61.50; S.D.= 6.473).
• Dysthymia T = -2.58*, F-M gender shows a lower average (M= 29.63; S.D.=
24.68) than M-F gender (M= 62.67; S.D.= 32.24).
• Alcohol Abuse T= -2.92**, F-M gender shows a lower average (M= 20.94; S.D.=
23.74) than M-F gender (M= 51.17; S.D.= 13.24).
• Drugs Abuse T= -2.84**, F-M gender shows a lower average (M= 40.06; S.D.=
18.71) than M-F gender (M= 63.50; S.D.= 11.88).
• Psychotic Thinking T= -2.23*, F-M gender shows a lower average (M= 36.50;
S.D.= 28.35) than M-F gender (M= 63.83; S.D.= 14.97).
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• Major Depression T= -3.38**, F-M gender shows a lower average (M= 26.19;
S.D.= 26.30) than M-F gender (M= 67.00; S.D.= 21.65).
Concerning MMPI-2, the following statistically significant differences in variables
were found:
• Lie T= 3.45**, F-M gender shows a higher average (M= 63.94; S.D.= 9.801) than
M-F gender (M= 49.17; S.D.= 5.636).
• Depression T= -3.86***, F-M gender shows a lower average (M= 47.06; S.D.=
10.45) than M-F gender (M= 66.50; S.D.= 10.71).
• Hysteria T= -2.99**, F-M gender shows a lower average (M= 52.69; S.D.=
9.046) than M-F gender (M= 65.83; S.D.= 9.559).
• Masculinity/Femininity T= -4.20***, F-M gender shows a lower average (M=
65.13; S.D.= 8.936) than M-F gender (M= 81.83; S.D.= 6.047).
• Paranoia T= -2.67*, F-M gender shows a lower average (M= 50.94; S.D.= 11.17)
than M-F gender (M= 65.17; S.D.= 11.04).
• Psychasthenia T= -2.70*, F-M gender shows a lower average (M= 49;75 S.D.=
13.34) than M-F gender (M= 68.00; S.D.= 16.54).
• Schizophrenia T= -2.57**, F-M gender shows a lower average (M= 54.31; S.D.=
11.72) than M-F gender (M= 71.33; S.D.= 18.84).
• Anxiety T= -3.09**, F-M gender shows a lower average (M= 47.67; \S.D.=
11.59) than M-F gender (M= 67.00; S.D.= 8.602).
• Fears T= -4.41***, F-M gender shows a lower average (M= 41.20; S.D.= 6.560)
than M-F gender (M= 58.50; S.D.= 8.660).
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• Obsessiveness T= -2.51*, F-M gender shows a lower average (M= 41.60; S.D.=
9.869) than M-F gender (M= 54.25; S.D.= 11.70).
• Health Awareness T= -2.38*, F-M gender shows a lower average (M= 46.60;
S.D.= 9.869) than M-F gender (M= 60.00; S.D.= 10.71).
• Ego strength T= 3.36**, F-M gender shows a higher average (M= 57.13; S.D.=
10.08) than M-F gender (M= 38.25; S.D.= 9.465).
• Masculine Gender Role T= 5.56***, F-M gender shows a higher average (M=
59.73; S.D.= 8.336) than M-F gender (M= 33.25; S.D.= 9.069).
• Feminine Gender Role T= -7.83***, F-M gender shows a lower average (M=
30.73; S.D.= 8.631) than M-F gender (M= 73.25; S.D.= 13.40).
• Psychological Gender Role T= -2.55*, F-M gender shows a one lower average
(M= 59.73; S.D.= 8.336) than M-F gender (M= 73.25; S.D.= 13.40).
• Depression D3 T= -3.29**, F-M gender shows a lower average (M= 48.40; S.D.=
8.634) than M-F gender (M= 67.75; S.D.= 16.42).
• Depression D5 T= -3.10**, F-M gender shows a lower average (M= 47.27; S.D.=
13.25) than M-F gender (M= 58.50; S.D.= 2.380).
• Paranoia P1 T= -2.15*, F-M gender shows a lower average (M= 53.25; S.D.=
10.55) than M-F gender (M= 67.00; S.D.= 14.45).
• Schizophrenia Sc3 T= -2.11*, F-M gender shows a lower average (M= 46.20;
S.D.= 8.152) than M-F gender (M= 57.25; S.D.= 13.38).
(See Table 28 – Appendix D)
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Differences in the various scales according to gender in Moment 2
At SCL-90 level, statistically significant differences were fund in the following
variables:
• Sleep disturbances, T = -2.09*, F-M gender shows a lower average (M= .31,
S.D.= .602) than M-F gender (M= 1.00 , S.D.= .894).
• Feelings of guilt, T = -2.28*, F-M gender shows a lower average (M= .31,
S.D.= .704) than M-F gender (M= 1.17 , S.D.= .983).
Regarding MMPI-2, the statistically significant differences found in these variables
were:
• Hypochondriasis, T = 2.11*, F-M gender shows a higher average (M= 52.00,
S.D.= 6.071) than M-F gender (M= 44.60, S.D.= 8.877).
• Masculinity/Femininity, T = 2.18*, F-M gender shows a higher average (M=
50.56, S.D.= 4.381) than M-F gender (M= 44.33, S.D.= 9.223).
(See Table 28 – Appendix D)
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CHAPTER FIVE
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
DISCUSSION
The principal difficulty found in the present study was the vast amount of data
yielded by the number of assessment instruments used to evaluate personality and subjacent
structures, psychopathology and levels of social adaptation. However, such a disadvantage
is offset by the opportunity afforded, namely the greater and solid clinical knowledge
acquired in a continuous and rigorous study of Gender Identity Disorder.
Group 1 – Gender Identity Disorder – Moment 1
Regarding general psychopathology levels, and in accordance with the data from the
Symptom-Check-List-90 Revised (SCL 90), transsexuals show higher rates in the
following dimensions: obsessive-compulsive, interpersonal sensitivity, anxiety, paranoid
ideation and depression. These results are in consonance with those of Monteiro (2002).
The subjects, at the moment of the first clinical assessment manifest unwanted, as well as
undesired, thoughts, impulses and actions, including cognitions and behaviors indicative of
general cognitive difficulties – 18.2% (Obsession-Compulsion scale); feelings of inferiority,
personal and interpersonal inadequacy – 22.7% (Interpersonal Sensitivity scale); agitation,
fear, tension and distress – 13.6% (Anxiety scale); disturbing thoughts – 13.6% (Paranoid
Ideation scale); and symptoms of clinical depression, such as isolation, dysphoric humor,
hopelessness, lack of interest and motivation – 31.8% (Depressivity scale). However, as far
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as clinical depression is concerned, it seems to be of small significance, as shown by the
data yielded by the Beck Depression Inventory (BDI). The BDI data show that only
13.6% of the subjects reveal depression of severe intensity and a further 9.1% show
moderate levels of depression. Of relevance are also the symptoms of sleep disturbance
such as insomnia and agitated sleep (Additional scales of the SCL-90).
Regarding the relationship between Interpersonal Sensitivity and variables in the
other questionnaires, as can be seen in the tables of the correlations matrices, at Moment 1
of the transsexuals, there is an association between the aforementioned dimension and
levels of depression (BDI), employment (QVSF), social activities and leisure time (QVSF),
social adaptation (QVSF), social introversion (MMPI-2), low self-esteem (MMPI-2), and
work interference (MMPI-2).
Thus, elevated interpersonal sensitivity seems to be
associated with higher levels of depression, greater difficulty at job level and with
occupation of leisure time, as well as lower levels of general social adaptation, greater
social introversion, lower self-esteem and also higher work interference.
The results of BDI also show statistically significant associations with other
dimensions. We’ve observed that the higher the level of depression, the higher work,
leisure time and extended family difficulties were seen, a higher general social discomfort,
a higher social introversion, a higher social discomfort and also higher negative treatment
indicators were found.
In clinical practice, it is common to find, in this population, symptoms related to
marked distrust and general cognitive difficulties, related to the internal conflict of identity.
The experience of feelings of loneliness and isolation, as well as feeling different from
others and general distress, all contributing to a low self-esteem, facilitate the development,
in many GID individuals, of depressive symptoms, consistent with the DSM-IV-TR (2000)
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and Saadeh (2004), intra and inter-personal inadequacy, confirmed by Ramsey (1998) and
sleep disturbances.
The present assessment questionnaires emphasize pertinent symptomatology that
need to be taken into clinical consideration. Nevertheless, there is the evident possibility of
the results found not corresponding to individual reality, as the instruments used are selfassessment, and therefore susceptible to individual manipulation. It must be borne in mind
that the results under consideration come from assessment measures used during the
clinical evaluation, with the aim of establishing (or not) the diagnosis of Gender Identity
Disorder. The nature of the assessment may naturally imply considerable bias in the selfassessment procedures. It is a possibility that the individual being assessed deliberately tries
to omit signs of emotional instability, fictional life stories, and altogether deny any
symptoms, in the belief that the presence of any pathology may negatively influence the
diagnosis, and consequently lead to the denial of the person’s greatest desire: namely,
professional confirmation of the identity conflicts experienced and subsequent
advancement of the Sexual Reassignment Process (SRP). According to clinic experience, in
the initial assessment it is common to fear transmitting real feelings and beliefs, to fear
being misunderstood when revealing their true identity. Such fears are of course based on
society’s, as well as, other people’s prejudiced reactions and rejection. This ostracism, to
which transsexuals have become habituated, promotes the need for individual protection
and self-defense, which will inevitably be projected onto the professionals, who make up
the multidisciplinary care team. The clinician is thus perceived both as someone who is
responsible for making the diagnosis of GID, but also as a representative of society at large.
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Accordingly, the clinician must possess a true understanding and acceptance of
human variability, as well as a very clear notion of such resistance, so as to enable the
person to acquire trust and a feeling of belonging to the multidisciplinary team.
The data from the Sociofamily Life Questionnaire (QVSF) revealed greater lack
of adaptation in the following scales: Social Activities and Leisure Time, Extended Family,
Spouse and Children. The global social adaptation score indicates the level of social
adaptation. The evidence for lack of adaptation, on the social activities and leisure time
dimension, was also referred by Monteiro (2002), on the extended family dimension, by the
DSM-IV (1994), Vieira (1996), Monteiro (2002) and Grossman et al (2005). However, the
difficulties in professional and/or academic adaptation referred by Ramsey (1998) were not
verified. The difficulties in marital life and in the relationship with children referred in the
clinic are usually perceived as mechanisms of self-protection. Many choose not to reveal
their true identity, (psychological gender), to their partners and/or to their children and, in
some circumstances, it may be the biological gender that is not revealed. This intermittent
life experience may actually facilitate emotional distance, and consequently reflect on the
assessment results.
The results of the QVSF may be interpreted in the light of feelings loneliness, being
misunderstood and the family rejection, all frequently present in the transsexual’s life, and
equally referred in the literature (Bullough & Weinberg, 1988; Gagne & Tewksbury, 1996;
Gagne et al., 1997; Bockting, Robinson & Rosser, 1998; Kammerer et al., 1999; Namaste,
1999; DSM-IV-TR, 2000; Bockting & Cesaretti, 2002; Monteiro, 2002). The present data
may also be viewed in the light of the individual suffering which in itself may allow the
distortion of the focus from inter-subjective conflicts.
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Regarding the association of the Social Adaptation score with other dimensions and
the variables yielded by the remaining instruments, it is possible to verify, in accordance
with the correlation matrix, that in the transsexuals group at Moment 1, there is an
association between this dimension and employment (QVSF), extended family (QVSF),
spouse (QVSF), social introversion (MMPI-2), low self-esteem (MMPI-2), social
discomfort (MMPI-2), work interference (MMPI-2), and negative treatment indicators
(MMPI-2). In the case of higher levels of general social adaptation difficulties, there are
also greater difficulties in employment adaptation, in relationship with the spouse and
extended family adaptation, greater social introversion, lower self-esteem, higher levels of
social discomfort, greater negative intrusion on professional adaptation and concomitant
negative treatment indicators.
The results on a Employment level show equally statistically significant associations
with other dimensions. It was verified that the greater the difficulties in employment
adaptation, the greater the difficulties in social activities and leisure time dimension, the
higher social introversion, the lesser self-esteem and the greater social discomfort verified.
The results of the Domestics Tasks dimension of the QVSF also show statistically
significant associations with other dimensions. It was shown that higher levels of difficulty
with domestic tasks chores correlated with higher levels of difficulty in adapting to social
activities and leisure time and extended family, lower general social adaptation and greater
social discomfort
The results at Leisure Time level also show statistically significant association with
other dimensions. We’ve found that the higher the difficulties in leisure time adaptation, the
higher the general social discomfort, the higher the difficulties in extended family
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adapation, the higher the social introversion, together with a lower self-esteem, and a higher
social social discomfort and also higher negative treatment indicators.
The Nuclear Family scores also show statistically significant associations with other
dimensions. They revealed that greater adaptation difficulties in nuclear family adaptation
are associated with greater difficulty in spouse and employment adaptation, higher levels of
general social adaptation, greater inconformity with biological gender characteristics,
higher levels of antisocial practices, lower self-esteem and more negative intrusion in
professional functions.
The Extended Family and Relationship with the Spouse scores also show
statistically significant associations with other dimensions. It was shown that greater
difficulties in the extended family and marital life are associated with higher social
introversion.
The MCMI-II – Millon Clinical Multiaxial Inventory. The scores yielded by this
instrument show an individual tendency for projecting social desirability and emotional
adaptation – 40.9% (Y scale – desirability); uncommon capacity for sharing emotional
difficulties – 22.7% (X scale – sincerity) and a real risk factor of suicide – 22.7% (risk
factor).
Regarding the basic personality pattern the following was shown: controlled and
prudent behavior due to a conflict between hostility from others and fear of social
disapproval – 40.9% (scale 7 – Compulsive); egotistical attitudes, primary pleasure
experiences simply by lasting passivity and egocentricity – 45.5% (scale 5 – Narcissistic);
irresponsibility and impulsivity experienced as justified, illegal behaviors with the aim of
manipulating so as to obtain self benefits, personal judgment considering that social norms
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do not have to be observed, superficiality, lack of self-control and the sentiment of having
been “ill-treated” in the past – 27.3% (scale 6A – Antisocial); vigilant and permanently
alert, distancing and avoidance of anticipated painful experiences or the (re)experiencing of
negative events – 22.7% (scale 2 – Phobic/Avoidance); seeking stimulation and affection,
intelligent social behaviors that transmit a misleading self-confidence and the need for
constant signals of acceptance and approval – 22.7% (scale 4 – Histrionic); incapacity for
profound feelings such as pleasure and pain, apathy, indifference, distance and
unsociability – 18.2% (scale 1 – Schizoid); the seeking of supporting relationships with the
aim of procuring affection and security – 18.2% (scale 3 – Dependent); and antagonist,
persecutory, domineering behavior – 18.2% (scale 6B – Agressive-sadic). Some scales
yielded scores lower than the normative scores, namely: Self-destructive (scale 8B – 50.0%),
Passive-aggressive (scale 8A – 45.5%), Phobic/Avoidant (Scale 2 – 31.8%), Dependent
(Scale 3 – 27.3%) and Schizoid (Scale 1 – 18.2%).
As far as personality disorders are concerned the results point to the following:
mistrust of others, anticipated defense against deception and criticism, irritability, fear of
losing independence, immutability of sentiments and thought rigidity – 22.7% ( scale P –
Paranoid); cognitive and interpersonal distance, preference for social distance, with
minimum obligations and personal involvement, probability of anxious precaution and lack
of affect – 18.2% (scale S – Schizotypical); and periods of sadness and apathy frequently
alternating with periods of anger, agitation or euphoria, recurrent thoughts of suicide or
self-mutilation, constant preoccupation in maintaining affects, cognitive-affective
ambivalence with anger feelings, love and guilt towards others – 9.1% (scale C –
Borderline). The more salient scales with below normative level scores were Borderline
scale (scale C – 45.5%) and the Schizotypical scale (scale S – 18.2%)
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Regarding clinical disturbances of moderate intensity the following were found:
symptoms of dysthimia, feelings of despair or guilt, lack of initiative and apathy,
expression of uselessness and self-devaluation, in periods of depression with suicidal
ideation, pessimism regarding the future, social withdrawal, lack of concentration, lack of
or excessive appetite, loss of interest and diminished efficiency in dealing with daily tasks –
18.2% (scale D – Dysthymia).
The clinical disturbances of severe intensity found were: irrational delusions of
persecution or of grandeur, hostility and expression of feelings of having been ill treated –
22.7% (scale PP – Delirious Disorder); profound feelings of being isolated and
misunderstood by others, retraction or alienation or “secret” or vigilant behaviors – 9.1%
(scale SS – Psychotic Thinking); and fear of the future, suicidal ideation and feelings of
resignation, state of profound sadness with changes in appetite, sleep and concentration,
feelings of uselessness or guilt – 4.5% (scale CC – Major Depression).
In Gender Identity Disorder, there are to be more frequently found, and with scores
of pathological intensity, narcissistic, compulsive, anti-social, avoidant and histrionic
personalities. Also with a high frequency, but of more moderate intensity, are to be found
the schizoid, dependent and agressive-sadic personalities. The results of Cole, O’Boyle,
Emory and Meyer (1997), confirm the presence of schizoid and anti-social personality
types. The latter is equally consistent with the data from Bodlund and Kullgren (1996) and
Monteiro (2002), whilst in the case of the histrionic personality type is consistent with the
studies of Blanchard et al. (1985), Kuiper and Cohen-Kettenis (1988), Landén et al.
(1998)in
134
. The schizotypical, borderline and paranoid personality disturbances are
frequent in this group of transsexuals. In the studies conducted by Breton, Frohwirt,
Gorceix and Kindynis (1981-1983)in
263
, this frequency has also been confirmed. The
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presence of a borderline personality is a congruent data with Cole, O´Boyle, Emory e
Meyer (1997) e com o DSM-IV-TR (2000).
The personality structures shown in group 1, were also referred by Hoening, Kenna
and Youd (1970); Derogatis et al.(1978), Dixen et al (1984), Beatrice (1985), Bodlund,
Kullgren, Sundbom and Hojerback (1993); Hartmann, Becker and Rueffer-Hesse (1997);
and, Monteiro (2002).
As to the clinical disturbances of moderate intensity, the most frequent one found
was dysthymia. In clinical disturbances of moderate intensity the most frequently found
was delirious disorder, followed by psychotic thinking and major depression.
The pattern of compulsive personality encountered is supported by Weissman and
Meyers (1978); Robins et al. (1984); Weissman et al. (1991)in
51
and the depressive
disturbance by Weissman and Meyers (1978); Robins et al. (1984); Weissman et al.
(1991)in 51; Breton Frohwirt, Gorceix and Kindynis (1981 e 1983)in 263; Brown, Wise and
Costa (1995)in 263; DSM-IV-TR (2000); and, Saadeh (2004).
Thus the results of the MCMI –II confirm the present research hypothesis 1 (H1),
regarding the prevalence of Avoidant Personality Disorder and Depressive Personality
Disorder in Gender Identity Disorder. However the research hypothesis 1 (H1), regarding
the prevalence of Borderline Personality Disorder was not confirmed. Nevertheless, in
group 1, it was found as prevalent a high narcissistic, compulsive, anti-social, avoidant,
histrionic, dependent and aggressive-sadic pattern, together with paranoid and schizotypical
personality disorders.
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In the results of the MMPI-2 – The Minnesota Multiphasic Personality
Inventory – 2, the most salient data are a defensive style, conventionality, strict moral
code and rigidity – 31.8% (scale L); conformity, possible false image projection and
sincerity – 36.4% (scale F) and exaggeration of one’s own difficulties, confusion, selfcriticism and introversion – 45.5% (scale K).
In the clinical scales the data pointed to: somatic preoccupations, demanding
reactions, exaggeration of physical problems, sleep disturbances, lack of satisfaction and
multiple complaints – 18.2% (scale 1 – Hs – Hypochondriasis); minor preoccupations with
the body and health related, emotional balance and awareness – 63.6% (scale 1 – Hs –
Hypochondriasis); severe clinical depression, withdrawal, despair, guilt, suicidal ideation
and psychomotor slowness – 9.1% (scale 2 – D – Depression); moderate depression, lack of
general satisfaction, preoccupations, withdrawal, lack of energy, disturbed sleep and
concentration, low self-confidence and self-devaluation – 22.7% (scale2- D – Depression);
somatic symptoms, sleep disturbance, lack of understanding the causes and symptoms,
negativity and immaturity – 36.4% (scale 3 – Hy – Hysteria); aggression, irresponsibility,
poor judgment, instability, egocentrism and immaturity – 4.5% (scale 4 – Pd- Psychopathic
Deviate); family problems, impulsivity, irritability, guiltiness, extroversion, superficial
relationships, energy and creativity – 45.5% (scale 4 – Pd- Psychopathic Deviate); conflicts
regarding gender identity, cross-gender attitudes and behavior – 54.5% (scale 5 – Mf –
Masculinity-femininity); severe conflicts in the sphere of sexuality – 31.8% (scale 5 – Mf –
Masculinity-femininity); possibility of paranoid psychosis – 9.1% (scale 6 – Pa –
Paranoia); paranoid predisposition, excessive sensitivity, anger, resentment and withdrawal
– 22.7% (scale 6 – Pa – Paranoia); extreme fear, anxiety and tension, thought and
perception disturbance, ruminations, lack of concentration, rigid rituals, irrational fears
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based on superstition and guilt – 9.1% (scale 7 – Pt – Psychasthenia); anxiety and moderate
depression, low self-confidence, guilt, perfectionism, indecision and conviction of the non
acceptance of self by others – 27.3% (scale 7 – Pt – Psychasthenia); possible schizophrenic
disturbance – 9.1% (scale 8 – Sc – Schizophrenia); schizoid pattern, tremor, confusion,
withdrawal, nightmares, excessive fantasizing and dreaming – 36.4% (scale 8 – Sc –
Schizophrenia); impulsivity, conceptual disorganization, excessive energy, low tolerance
threshold to frustration, small notion of self-valuation – 4.5% (scale 9 – Ma – Hypomania);
extreme reserve – 9.1% (scale 0 – Si – Social Introversion); and introversion, withdrawal,
timidity, depressive symptoms, severe control, personal insecurity, lack of interests,
submission, condescension, formality and professional responsibility – 22.7% (scale 0 – Si
– Social Introversion). The scales with scores below the normative pattern score are:
Psychastenia (scale 7 – Pt – 22.7%), Hypochondriasis (scale 1 – Hs – 18.2%) and
Depression (scale 2 – D- 18.2%).
Regarding the supplementary and content scales there is an emphasis on greater
gender role conformity regarding psychological gender (GP) in comparison with biological
gender role (GB), marital distress (MDS), anxiety (ANX), and depression (DEP).
The results point to depression (consistent with Weissman & Meyers, 1978; Robins
et al., 1984; Weissman et al., 1991in 51; Breton, Frohwirt, Gorceix & Kindynis (1981-1983)in
263
; Brown, Wise & Costa, 1995in
263
; DSM-IV-TR, 2000; e, Saadeh, 2004), social
introversion (consistent with the results of Monteiro, 2002), paranoid disturbance,
psychopathic deviate, schizoid pattern, and psychoasthenia as the most frequent
psychopathologies in transsexuals.
The high scores found on the psychopathic deviate scale are consistent with the
results of Breton, Frohwirt, Gorceix and Kindynis (1981-1983)in 263, and Cole, O´Boyle,
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Emory and Meyer (1997). The high scores on the masculinity-femininity scale point to
transsexuals showing gender characteristics stereotypical of the opposite sex; these results
are in accordance with the results of Walinder (1967); Fleming et al. (1980, 1984); Skrapec
and Mackenzie (1981); Brems et al. (1993); Collier et al. (1997)in 134; Breton, Frohwirt,
Gorceix and Kindynis (1981-1983)in
263
; Cole, O´Boyle, Emory and Meyer (1997);
Herman-Jeglińska, Grabowska and Dulko (2002); and, Coussinoux et al. (2005).
Therefore the results of the MMPI-2 confirm the research hypothesis 1 (H1),
regarding the prevalence of Depressive Personality Disorder, in accordance with the other
assessment instrument, namely MCMI-II.
Regarding the relationship between the Biological Gender Role and other variables,
the correlation matrix tables show that, in the transsexual group at Moment 1, there is an
association between this dimension and the BDI score, employment (QVSF), domestics
tasks (QVSF), social activities and leisure time (QVSF), extended family (QVSF), spouse
(QVSF), social adaptation (QVSF), low self-esteem (MMPI-2), social discomfort (MMPI2) and the negative treatment indicators (MMPI-2). A greater inconformity with biological
gender role is associated with higher levels of depressive symptoms, greater difficulties in
adaptation to employment, domestics tasks, social activities and leisure time, extended
family and marital life, greater lack of general social adaptation, lower self-esteem, higher
levels of social discomfort and greater levels of negative treatment indicators.
The results of the Social Responsibility scale also show statistically significant
associations with other variables. It was shown that greater social responsibility and greater
conformity with psychological gender role are associated with lower rates of antisocial
practices, better self-esteem, less negative professional intrusion and lower negative
treatment indicators.
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The correlation matrix tables also show that the greater Social Introversion is
associated with higher social discomfort, lower self-esteem, greater negative work
interference; lower levels of Self-Esteem are associated with higher levels of negative
influence on work adaptation and higher levels of negative treatment indicators; and higher
levels of Work Interference are associated with negative treatment indicators.
Group 2 – Gender Identity Disorder – Moment 2
According to the results of the Symptom-Check-List-90 Revised (SCL 90), which
measures general psychopathology, the transsexual group does not show higher scores on
the various individual dimensions. As it were, at post sexual reassignment surgery (SRS)
assessment, only one subject showed scores above the normality threshold in the following
dimensions: somatization, obsession-compulsion, phobic anxiety and paranoid ideation.
According to Beck Depression Inventory (BDI), all subjects in group 2 showed no
symptoms of depression. However, this absence is not in accordance with the results found
by Barrett (1998).
Regarding the relationship between the BDI scores and the other variables, the
correlation matrices tables of the scores of the transsexual group, at the post SRS
assessment, show an association between BDI scores and interpersonal sensitivity (SCL90), domestics tasks (QVSF), and antisocial practices (MMPI-2). Lower levels of
depressive symptoms are associated with lower interpersonal sensitivity, lesser difficulty
with domestic tasks and less antisocial practices.
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In the Sociofamily Life Questionnaire (QVSF) scores there is no evidence for lack
of adaptation in the various dimensions, pointing to a general social adaptation, as well as
adaptation in the various sub-dimensions. These results are in accordance with those of
Carroll (2000); Goméz Gil, Nogués, Perpiná and Rabassó (2001); and Cuypere et al. (2006).
Regarding the relationship between Social Adaptation with other dimensions and
the variables form the other instruments, as can be verified in the correlation matrices tables,
the transsexual group, at post SRS, show an association between this dimension and a lower
self-esteem (MMPI-2), social discomfort (MMPI-2) and negative treatment indicators
(MMPI-2). Higher levels of general social adaptation imply a better self-esteem, lower
levels of social discomfort and lower negative treatment indicators.
Throughout the correlation matrices tables, it could equally be observed that lesser
negative Employment interference is associated with lower general social adaptation
difficulties; lower negative influence on Domestic Tasks adaptation is associated with
lesser difficulties in extended family and general social adaptation and lower levels of
social discomfort; better adaptation scores in the sub-dimension Social Activities and
Leisure Time is associated with lesser adaptation difficulties to the extended family and
general social adaptation, lower levels of social discomfort and greater difficulty in nuclear
family adaptation; better Extended Family adaptation is associated with higher self-esteem,
better general social adaptation and lower negative treatment indicators; the lesser
interference in Relationship with the Spouse is associated with lower rates of antisocial
practices, less work interference and higher scores in the assumed gender characteristics;
the lesser level of interference with children, is associated with higher self-esteem, lower
levels of social discomfort, less social introversion and lower conformity with
psychological gender role.
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The MCMI-II – Millon Clinical Multiaxial Inventory data point to an individual
tendency for projecting both a favorable image and emotional adjustment – 36.4% (scale Y
– desirability).
Regarding the basic personality pattern data pointed to the following pathological
personality patterns: compulsive (36.3%), narcissistic (36.3%), anti-social (22.7%),
histrionic (27.3%) and aggressive-sadic (22.7%). Also found, are the following scales
bellow normative threshold levels: Self-destructive (scale 8B – 54.5%), Passive-aggressive
(scale 8A – 54.5%), Phobic-avoidant (scale 2 – 31.8%), Schizoid (scale 1 – 18.2%) and
Dependant (scale 3 – 18.2%).
Regarding personality disorders the results point to a prevalence within the limits of
normality. Bellow this threshold are the scales Paranoid (scale P – 36.4%) and Borderline
(scale C – 31.8%).
At the clinical disturbances level of moderate intensity, the absence of prevalence
above normative patterns was highlighted.
At the clinical disturbances level of severe intensity, the absence of frequency of
values considered as pathological was also observed.
In group 2 there is evidence pointing to the existence of high levels of the following
personality patterns: compulsive, narcissistic, anti-social, histrionic and aggressive-sadic.
However it must be pointed out that no personality disturbances were found.
The MMPI-2 – The Minnesota Multiphasic Personality Inventory – 2 – scores
point to scale L (22.7%) and scale K (59.1%) as having been scored above the normative
pattern.
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As to the clinical scales evidence pointed to the existence of: severe clinical
depression- 4.5% (scale 2 – D – Depression); moderate depression – 13.6% (scale 2 – D –
Depression); family problems, impulsivity, irritability, guilt, extroversion, superficial
relationship, energy and creativity – 18.2% (scale 4 – Pd – Psychopathic Deviate); and
paranoid predisposition – 18.2% (scale 6 – Pa – Paranoia). The following scales were
scored below the normative level: Social Introversion (40.9%- scale 0 – Si), Hypomania
(22.7% – scale 9 – Ma), Psychastenia (18.2% – scale 7 – Pt), Depression (18.2% – scale 2
– D) and Masculinity-femininity (18.2% – scale 5 – Mf).
The fact that the masculinity-femininity scale scores were not, with greater
frequency, above the normative threshold level, can be attributed to the Moment 2 having
taken place post SRS and thus what was taken into consideration was the personality profile
of the psychological gender. Thus it seems, as the average scores show, transsexuals show
gender characteristics in consonance with their gender identity. Again the scores below
normative levels point to an intense demonstration of gender characteristics stereotypical of
gender identity.
In the case of the supplementary and content scales the scores evidence
Overcontrolled Hostility (O-H) and a pattern of values in consonance with biological
gender role (BG) and psychological gender role (PG). It must be borne in mind that at this
assessment moment, the subjects were evaluated considering as the basis for the personality
profile, the post surgery gender profile.
Regarding the relationship between Biological Gender Role and other variables, the
data derived from the correlation matrices, shows that post SRS assessment, there is an
association between this variable, the BDI scores, and extended family (QVSF), social
adaptation (QVSF), antisocial practices (MMPI-2), low self-esteem (MMPI-2), work
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interference (MMPI-2), and negative treatment indicators (MMPI-2). Greater gender role
inconformity with biological gender is associated with higher levels of depressive
symptoms, greater difficulties in general social adaptation, higher levels of antisocial
practices, lower self-esteem, higher work interference and greater levels of negative
treatment indicators.
The results of the dimension Social Responsibility also show statistically significant
associations with other dimensions. It was shown that higher levels of social responsibility
are associated with higher values regarding biological gender role and psychological gender
role, as well as longer duration of the gender reassignment process and lower antisocial
practices.
Yet again the correlation matrices tables showed that lower Social Introversion is
associated with greater self-esteem and lower levels of social discomfort; lower levels of
antisocial practices are associated with higher self-esteem, lower work interference and
lower negative treatment indicators; higher Self-esteem levels are associated with lower
levels of social discomfort, lower work interference and lower negative treatment
indicators; lower levels of Work Interference are associated to lower levels of negative
treatment indicators; higher values of psychological gender stereotyped characteristics are
associated with a longer duration of the SRP; and a longer Duration of the SPR is
associated with higher rates of anti-social behaviors.
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Comparison between Moment 1 and Moment 2 – Gender Identity Disorder
At Moment 2, after Sexual Reassignment Surgery, when we compare this group of
individuals with Gender Identity Disorder with M1, Moment of Clinical Evaluation, we can
point the following out:
• Higher number of individuals with a university degree, and with a better level of
professional activity. The number of unemployed patients has decreased. It should be
highlighted that throughout the SRP, this group of individuals have also invested in
education which might have granted them better professional opportunities. However,
another relevant feature is society in which they are inserted. Thanks to the prevailing
social attitudes, and media sensationalism, and sometimes incoherence, when addressing
“sex change”, transexuality remains an unknown universe, and quite painful for these
patients. One reality is public expression, being private expression another one. The
suffering experienced, in spite of being invisible to others, is neglected and sometimes they
feel ridicule, and discriminated when their legal documentation is requested by the
authorities. These documents exhibit a name and a gender opposed to their physical
appearance and this inevitably reduces their socio-professional integration. This means that
besides their inter-subjective conflicts, they have to fight and face countless sacrifices, as
economic difficulties, job loss/unemployment, family problems, relation and intimate
problems, and additional difficulties with authorities and entities in their own environment,
to be able to live with their perceived to be their true identity. When the SRP is complete,
the possibility of facing society with their gender role in full, without facing ostracism,
insensibility and embarrassment, allow them more and better and legitimate opportunities.
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These results at a professional level, observed between M2 and M1, are in line with
those from Carrol (2000); Goméz, Gil, Nogués, Perpiná and Rabassó (2001); and Green
(2007).
• Higher frequency of married individuals, existence of children, although not
biological, and a stable relationship, for 3 or more years. These results remit us to the
importance of an individual journey, in their life cycle, and the formation of a nuclear
family. The increase in duration of the erotic-affective relationship observed, highlights the
importance of the maintenance of the same partner. These results are not in line with those
from Breton, Frohwirt, Gorceix and Kindynis (1981-1983)in
263
, and Barrett (1998) but
congruent with the work of Cuypere et al. (2006).
• Lower percentage of individuals with psychiatric care, and most already
completed; lower percentage of individuals with psychotherapeutic intervention, since the
majority of co-morbidities have decreased, keeping the process/support with a variable
periodicity, specifically adapted to the individual needs; lower frequency of psychotropic
intake (anxiolytics and/or antidepressants), due to the non existence of clinical indication.
• Lower frequency of symptomatic psychopathology. We’ve also found lower
intensity and frequency of psychopathology, namely at interpersonal sensitivity level,
depressivity, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism, with
significant differences in somatization and at the obsession-compulsion dimension.
• Higher prevalence of normality, and absence of general psychopathology.
interpersonal sensivity and depressivity show statistically significance.
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• Lower frequency in the dimensions low self-esteem, post-traumatic stress,
cynicism, negative treatment indicators, guilt and loss of appetite, initial insomnia, suicidal
thoughts and restless sleep, with significant differences.
• Higher frequency of increased appetite, terminal insomnia and in the variable
dominance, with significant differences.
• Higher prevalence of normality and absence of suicidal risk, with statistically
significant differences.
• Higher prevalence of normality in the various clinical dimensions. The clinical
disorders of severe intensity were absent, namely psychotic thinking, major depression and
delirious disorder, absence of hysteriform disorder and alcohol abuse; and, in a lower
frequency, anxiety, hypomania, dysthymia and drugs abuse.
• Lower prevalence of depression, as demonstrated in various dimensions and
clinical scales. In some instruments, depressive symptoms were absent, with statistically
significant differences.
These results, at an emotional stability level, verified between M2 and M1, are
consistent with those from Carrol (2000); Smith, Cohen and Cohen-Kettenis (2002); and
Cuypere et al. (2006) and, with what Haraldsen and Dahl (2000) and Monteiro (2002) have
suggested. Notwithstanding, the absence of depressive symptoms is not in line with the
findings of Barrett (1998).
Accordingly, and after the analysis of these results, at Moment 1 and Moment 2, we
can confirm the research hypothesis 3 (H3iii.), of psychopathological significant
differences in the results of M1 evaluation, when compared to those of M2 evaluation.
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Through the tables and correlation matrixes, we may verify the association of
clinical and social conditions at M1 with M2. Depressive symptoms, difficulties and social
maladjustment at various levels, at M1, show an influence in their role in society and in
their intra and inter-personal experiences, at M2.
• Lower social maladaptation at a global level, with significant differences, at the
following levels: social introversion, shyness/self-consciousness, social avoidance, self and
others alienation, marital distress, social discomfort and family problems.
• Higher frequency of adaptation to domestic tasks, children, nuclear family, and,
with significant differences, at work, leisure, extended family and marital family levels.
• Higher prevalence of social responsibility, and general social adaptation, with
statistically significant differences.
The negative experiences of incomprehension and rejection, associated to one’s
great suffering, turn their adaptation considerably harder, as verified at M1, in which
they’re focused on an internal fight for survival. These results of social adaptation, obvious
at various levels, at M2, may be associated to the fact that, actually, these individuals feel
themselves completely accepted by the society, which, associated to a lesser/absent
psychopathology, enables an easier insertion.
These results of social adaptation, verified between M2 and M1, are in accordance
to Ross e Need (1989); Carrol (2000); Haraldsen and Dahl (2000); Goméz, Gil, Nogués,
Perpiná and Rabassó (2001); Cuypere et al. (2006); and, Green (2007).
After the analysis of these results, at Moment 1 and at Moment 2, we can confirm
the research hypothesis 3 (H3iv.), of a better general social adaptation of transsexuals at
M2 when compared to M1.
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• Higher prevalence of normality, at the basic pattern and personality structure
levels. We’ve found the absence, statistically significant, of a high schizoid pattern of
personality, lack of schizotypical personality disorder, with significant differences; lack of
borderline personality disorder, and lower frequency of paranoid personality disorder, also
with significant differences.
Accordingly, and through these results, at Moment 1 and at Moment 2, we confirm
the research hypothesis 3 (H3i.), of higher frequency of Personality Disorders in
transsexuals at M1 when compared to the same group of transsexuals at M2.
• Lower frequency of a high compulsive personality pattern, narcissistic, anti-social,
avoidant and dependent; on the dimensions hypochondriasis, hypomania, hysteria,
psychopathic deviate, masculinity-femininity, psychastenia, schizophrenia, all with
significant differences.
• Higher frequency of a high histrionic and agressive-sadic personality pattern.
• Higher frequency, above the lower threshold of normality, of passive-aggressive
and self-destructive personality patterns, paranoid structure of personality, with significant
differences, and in the dimensions hypomania, psychopathic deviate and hysteria.
• Lower frequency, above the lower threshold of normality, of the dependent, antisocial and compulsive patterns of personality, of schizotypical structure and borderline
personality, and also in the dimensions hypochondriasis, psychasthenia and schizophrenia.
As a consequence, and after the analysis of the data, at Moment 1 and at Moment 2,
we can therefore confirm the research hypothesis 3 (H3ii.), of significant differences at the
personality pattern of transsexuals at M1 when compared to M2.
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It became evident, at M2, and according to the results, the decrease in frequency of
personality disorders and of the pathological pattern of personality.
In some dimensions, in spite of the fact it wasn’t possible to find significant
differences due to the small number of individuals in this study, we can observe differences
in the proportion of normality indexes, at the personality structure level. Therefore we’ve
highlighted a trend that suggests a change in the basic personality pattern of the personality
profile. We’ve check that trend and the significant changes, as seen in Fig. 2, through the
reduction of a pathologic personality structure, a decrease in the normative pattern and also
through the raise of dimensions that led to a normative pattern of personality.
Above threshold
M1
Normative pattern
(personality pattern)
M2
M2
M1
M1
M2
Below threshold
Figure 2 – Changes, statistically significant, and trend, of personality profile at M2.
This evidence, at the personality structure level, reinforces what had been suggested
by Monteiro (2002), on the basis of her work on the SRP phases before Sexual
Reassignment Surgery.
• Equitable frequency in the dimension psychological gender role, in which, at both
Moments, show averages within the normal range.
• Higher frequency in the dimensions biological gender role, and feminine gender
role, with significant differences.
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These results highlight, at M2, a major normative pattern in which biological gender
role is concerned. The fact that no significant differences were shown in the proportion of
psychological gender role, between M1 and M2 refers is congruent, as it demonstrates
stereotyped gender characteristics of their psychological sex.
Regarding feminine gender role, a higher value at M2, when compared to M1, is
due to the fact that the sample is more representative of F-M individuals than M-F patients,
and also because they were evaluated, at M1, according to their biological sex (mainly F-M,
which decreases the feminine gender role).
Through the correlation tables and matrixes, it’s still possible to conclude:
• Whenever a higher unconformity with the gender role referred to the biological
sex is observed, at M1, there is a better general social adaptation, higher levels of selfesteem, lesser professional interference and fewer negative treatment indicators, at M2.
• The highest conformity with the gender role referred to the psychological sex, at
M1, the better conformity with the gender role according to their sexual identity, at M2.
Considering that at M1, these individuals were evaluated according to their
biological sex, and at M2, according to their psychological sex, we took great care in the
analysis and understanding of the results, also at the gender role level, according to the
Moment. However, during the process of loading the data into the statistical software, we
have found a higher similarity of values at M2, in which biological and psychological
gender role were concerned, a very interesting and curious fact. When this perception was
confirmed, after the analysis of the results, we’ve found a discrepancy of values, with a
higher difference, between biological and psychological gender roles at M1 than at M2.
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This led us to raise the question of how would proceed the components of gender role at
M2, if analyzed according to the biological gender role when compared to M1, and also
when compared with the evaluation already made according to the psychological sex. To
the best of the researcher’s knowledge, this analysis has never been done, and this new
question was considered as relevant to be added to this study as a new research hypothesis:
H4 – Differences in Gender Role
i. Significant differences, at M2, in gender role evaluated according to the
psychological sex, when compared to the evaluation according to the
biological sex;
ii. Significant differences in psychological gender role evaluated according
to the biological sex, at M1, when compared to M2;
iii. No significant differences in biological gender role evaluated according
to the biological sex at M1 when compared to M2.
Facing a new research hypothesis, an evaluation of gender role according to the
biological sex was done, and also the descriptive analysis, differences and correlation
matrix.
- 224 -
Table 29
Descriptive statistics of the intervals in the Scales Gender Role of the Minnesota
Multiphasic Personality Inventory – 2 (MMPI-2) according to the type of Evaluation and
the Moment
Moment 1
GBb – Biological Gender Role
Evaluation according to biological sex
< 40
40-65
> 65
GPb – Psychological Gender Role
Evaluation according to biological sex
< 40
40-65
> 65
GBp – Biological Gender Role
Evaluation according to psychological sex
< 40
40-65
> 65
GPp – Psychological Gender Role
Evaluation according to psychological sex
< 40
40-65
> 65
Moment 2
N
%
N
%
16
3
0
72.7
13.6
.0
20
2
0
90.9
9.1
.0
0
13
6
.0
59.1
27.3
0
8
14
.0
36.4
63.6
-
-
2
16
4
9.1
72.7
18.2
-
-
0
19
3
.0
86.4
13.6
According to the intervals, as seen on Table 29, we can conclude:
• Equitable frequency of the biological gender role (evaluation according to
biological sex), showing mainly low values.
This puts in evidence how solid the data is, as the incongruence between gender
identity and biological gender role, already shown at M1, is maintained after sexual
reassignment surgery.
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As a consequence, and analyzing the data, at Moment 1 and Moment 2, we confirm
the research hypothesis 4 (H4iii.), of no significant differences at the biological gender role
level evaluated according to the biological sex at M1, when compared to M2.
• Higher frequency of high values in the dimension psychological gender role, at
M2 (evaluation according to biological sex). Significant differences were found in the
proportions “>65” at the two Moments in the variable evaluation GPb (Z= -2.42**), in
which M2 exhibits a significant higher proportion (%= 63.6) when compared to M1 (%=
27.3).
This data reinforces that, beyond congruence between their gender identity and their
psychological gender role, already established at M1, an increment in this social
representation was seen, which may be related with the way how they present themselves
and are socially accepted, actually entirely in conformity with their gender identity.
The analysis of this data, at Moment 1 and Moment 2, confirms the research
hypothesis 4 (H4ii.), of significant differences at the psychological gender role level
evaluated according to the biological sex at M1, when compared to M2.
According to the differences and correlation matrix, between M1 and M2, when
evaluated according to the biological sex, we can conclude:
• Biological gender role, at M2, shows higher values than biological gender role and
psychological gender role, at M1, with significant difference.
• Biological gender role, at M2, shows higher values than biological gender role, at
M1, and lower values than psychological gender role, at M1, with significant difference.
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The data demonstrate that the higher the psychological gender role is, at M1, the
higher the biological gender role and the psychological gender role are, at M2; and also, he
greater the biological gender role at M1 is, the greater the biological gender role at M2 is.
(See Tables 30 and 31 - Appendix D)
Within the same parameters of evaluation, after sex reassignment surgery, the group
of transsexuals shows values in total conformity with their gender identity, confirming a
consistency and even reinforcing their masculine gender role in F-M and feminine in M-F
transsexuals.
Regarding the values of biological gender role at M2, despite their raise when
compared to M1, we can observe standardization, maybe associated to a better adaptation
and social interaction. If we consider that gender role discriminates the way how we present
ourselves to others in society, and that independently of the gender, every individual
exhibits standardized characteristics of the opposite gender, this data maybe be associated
with the fact that a higher social alienation at M1, for individual protection, which explains
why these values were below the normative threshold. This possibility is therefore
reinforced when we see that the psychological gender role is also higher at M2. Actually
they have a larger social exposure, and consequently a higher representation of gender
characteristics, with an intensification of a consistent gender role with their identity, and a
standardization of a cross gender role. The fact they have a better self-confidence,
emotional stability, and self-acceptance, also brings the individual permission to expose
themselves in a more spontaneous way to others, without inhibitions due to fears of
extrinsic reactions.
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According to the differences and correlation matrix, between M1 (evaluation
according to biological sex), and M2 (evaluation according to the psychological sex) we
can conclude:
• Biological gender role, at M2, shows higher values than biological gender role, at
M1, with significant differences.
• Psychological gender role, at M2, shows higher values than biological gender role
and lower values than psychological gender role, at M1, with significant differences.
The data demonstrate that the higher the biological gender role at M1 is, the higher
the biological gender role at M2 is; and also that the greater the psychological gender role
at M1 is, the greater the psychological gender role at M2 is. (See Tables 30 and 31 - Appendix D)
These results are consistent with those previously found, of conformity with the
gender identity and standardization of gender roles. As these individuals have already been
submitted to the sex reassignment surgeries, the acceptance of their gender in line with their
identity, became normative, on the basis of their personality profile evaluation, which goes
along with their adequacy and values standardization.
At M2, according to the differences and correlation matrix, between the evaluation
according to the psychological sex and the evaluation according to the biological sex, we
can conclude:
• Higher values, with significant difference, on the psychological gender role, when
evaluated according to the biological gender role, when compared with the psychological
gender role and biological gender role, according to their gender identity.
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• Lower values, with significant difference, on the biological gender role, when
evaluated according to the biological sex, when compared with the biological gender role
and the psychological gender role, according to their gender identity.
The data demonstrate the higher the psychological gender role according to their
gender identity is, the higher the psychological gender role and the biological gender role
when evaluated according to their biological sex is; and also, the greater the biological
gender role according to their gender identity is, the greater the psychological gender role
and the biological gender role, when evaluated according to the biological sex is. (See Tables
30 and 31 – Appendix D)
These results shown at M2, according to the way they were evaluated, leads to a
better balance of gender roles when evaluated according to their gender identity.
After the analysis of these results, at Moment 2, we can confirm research hypothesis
4 (H4i.), of significant differences, at M2, at gender role level, when evaluated according to
the psychological sex, when compared to the evaluation done according to the biological
sex.
Gender Differences
We’ve found, at Moment 1, gender differences, with the M-F group showing higher
values in general psychopathology when compared to the F-M group in the following
dimensions:
somatization,
obsession-compulsion,
depressivity,
paranoid
ideation,
psychoticism, death thoughts, restless sleep, guilt and in the general index of symptoms.
We’ve detected, at Moment 1, gender differences, with the M-F group exhibiting
higher values at personality structure level and clinical dimensions, when compared with
the F-M group of patients, namely: phobic/avoidant pattern, dependent, passive-aggressive
- 229 -
and self-destructive of personality, schyzotypical and borderline of personality; clinical
disorders: Hysteriform, hypomania, dysthymia, alcohol abuse, drugs abuse, psychotic
thinking and major depression; at clinical dimensions level: hyponcondriasis, hysteria,
masculinity-femininity, paranoia, psychasthenia, schizophrenia, depression, anxiety, fears,
obsessiveness, health concerns, feminine gender role, psychological gender role, physical
dysfunction, rumination, persecutory ideas and lack of cognitive self-control.
Analyzing these results, we can conclude that feminine gender role is congruent
with gender identity of group M-F, and also congruent with gender identity of the group FM. The fact that group M-F shows higher values in the scale masculinity-femininity, does
not prevent individuals from group F-M to demonstrate roles, interests and male
stereotyped attitudes. The higher results in the group M-F may be related with their need
for a most marked positioning, due to others higher perception of their cross gender
changes, and also due to the inherent lower social acceptance. Notwithstanding, when
analyzing Moment 1 and Moment 2, these differences prove to be significant in both
groups, F-M and M-F, referring a higher balance, and equally, for the group M-F after
sexual reassignment surgery. We can therefore understand the role of a possible better
social acceptance, through a progressive process, or just due to the lack of perception of the
journey made by these individuals.
We’ve found, at Moment 1, gender differences, with the F-M group exhibiting
higher values, when compared with M-F group, in the following dimensions: compulsive
pattern of personality, ego strength and masculine gender role. Analyzing these results we
can conclude that masculine gender role is congruent with gender identity of group F-M
and also congruent with gender identity of group M-F.
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Group M-F faces more intra and interpersonal difficulties possibly due the lower
social acceptance of a man who dresses and behaves like a stereotyped woman. On the
other hand, F-M group faces fewer difficulties due to a better acceptance of a woman who
dresses trousers, who behaves like a man and has male interests, which can even be seen,
in modern society, as a trigger of professional and cultural advantages. As a consequence,
F-M group show a better general adaptation when compared to M-F group.
The results of gender differences, mostly higher in group M-F, are similar to the
data gathered by Pauly (1974)in 134; Breton, Frohwirt, Gorceix and Kindynis (1981-1983)in
263
; Bodlund e Kullgren (1996); Vieira (1996); Boldlund e Kullgreen (1996); Herman-
Jeglinska, Grabowska e Dulko (2002); Monteiro (2002); Wallien, Van Goozen et al. (2007).
The alcohol abuse, more common in the group M-F, is similar to what we can observe in
the general population.
Thus, and analyzing the results, we can confirm research hypothesis 2 (H2i.), of
higher frequency of Personality Disorders in the group M-F transsexuals when compared to
the group M-F.
We’ve also found, at Moment 2, gender differences, with the M-F group exhibiting
higher values, when compared with the F-M group, in the restless sleep and guilt
dimensions.
At Moment 2, gender differences were also detected, with the group F-M showing
higher values, when compared with group M-F, in the hypochondriasis and masculinityfemininity dimensions. These differences might be explained thanks to the sociodemographic characteristics of the sample, since more F-M individuals were obtained in
this research. Notwithstanding, and considering that F-M patients are submitted to more
surgical procedures during their SRP, maybe the associated concerns with their health
- 231 -
status, and eventual complications after sex reassignment surgeries, may contribute to the
hypochondria highlighted in the results.
Accordingly, at Moment 2, the group of transsexuals shows a lower frequency of
significant gender differences when compared with Moment 1, and the values are quite
similar between M-F and F-M.
When analyzing the differences between Moment 1 and Moment 2, we can find
gender differences at various levels of social adaptation. In the group F-M the significant
dimensions are: extended family, marital family, general social adaptation, shyness/selfconsciousness, social avoidance, marital distress, social discomfort and social responsibility.
On the other hand, group F-M of patients show a significant social discomfort dimension.
The data suggest a better global social adaptation of group F-M at Moment 2, when
compared with Moment 1, and more significant when compared to the group M-F, at
Moment 2.
The analysis of these results enables to confirm the research hypothesis 2 (H2ii.), of
a better general social adaptation of F-M group of transsexuals when compared with F-M
transsexuals.
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CONCLUSIONS
After the analysis of the results we can conclude its consistency with the research
hypothesis initially formulated.
The present study allows us to conclude that Gender Identity Disorder does not
emerge as an isolated clinical entity. Its experience leads to an inherent co-morbidity that
must be considered during the diagnosis phase, and respective specific clinical evaluation.
The underlying characteristics of M-F and F-M individuals’ personality seem to be
universal in different contexts. However, after Sexual Reassignment Surgery (SRS), the
intensity in the gender differences fades away, which puts the option of the influence of the
deported experience, in accordance to the biological gender role during the years previous
to the Sexual Reassignment Process (SRP), may exhibit throughout their entire life cycle
after the SRP.
We can therefore conclude that in Gender Identity Disorder, following Sexual
Reassignment Surgery, significant clinical changes does occur. They’re put in evidence at
the clinical and personality disorders level, as well at the social adaptation level. This data
becomes even more relevant when we consider that these changes refer to an equilibrium
and stability in various dimensions. This information grants guidelines that should be
considered for a better acuity in the clinical care in this area. The positive evolution
highlights the importance of the Sexual Reassignment Process, with an emphasis on the
effective evidence of a stability conquered in dimensions like psychoticism, without the use
of anti-psychotic drugs. Besides the full consequent gender adequacy, and the essential
- 233 -
clinical intervention, other factors possibly contribute to this evolution, namely society!
Either we face a gradual acceptance or a complete ignorance, there is permission for a
natural social insertion. It became evident that the suffering experienced by these
individuals is nothing but a reflex of our own behaviors and attitudes. We consider that,
beyond clinicians, we should reflect as members of a society… and also that we, society,
can have an active role before these issues. Do we cooperate or do we make it more
difficult?
In face of the relevant associations between the various clinical and social
conditions, previous to, and after Sexual Reassignment Surgery, we may conclude that
preventive measures are needed in view of the identified factors, for these individual’s
benefit, throughout and after their Sexual Reassignment Process. Besides a necessary
clinical intervention, the validation of the influence of the SRP length in Portugal, should
be duly considered, and we admit a real need for adjustment and correction in which the
burocratic proceeding are concerned, that leads to a fruitless extension of this process with
consequent individual interference.
With this study we can conclude that changes in personality profile effectively
exists in Gender Identity Disorder, after Sexual Reassignment Surgery. Therefore
significant changes do exist when we compare the initiation of the Sexual Reassignment
Process, not only at a psychopathological level, but also in the basic structure of personality.
This makes the probable changes more solid, not only in this clinical population, raising the
real possibility of changes at this level, previously defined as immutable.
- 234 -
We conclude, after the data analysis, the existence of a better balance, at various
levels, when these individuals are envisaged and evaluated according to their gender
identity. This data is of extreme importance during the clinical evaluation, the whole
process and up to the completion of the SRP, allowing us to clarify strategies to be adopted
in clinical practice in a more solid way. We can also conclude the full consistency of the
coherent gender role with the gender identity. Consequently, the continuous and complete
Sexual Reassignment Process is the effective resource to overcome social, religious, ethical
and psychological conflicts, enabling an intra and inter-subjective individual stability.
Permission to live … life to your days!
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RECOMMENDATIONS
The limitation of this study, namely a non-balanced sample (number of F-M/M-F),
the total number of individuals, and the fact that some of them were still waiting for the
legal recognition, are facts that to a certain extent may influence (although not in a
significant way) the results at Moment 2. For these reason a few recommendations are
presented.
A continuation of this study, with an enlarged clinical sample.
The symptoms evaluation through various instruments in the present study suggests
the possibility of reducing the number of questionnaires in a subsequent research. Namely,
the depressive symptoms were evaluated by various dimensions, and we’ve concluded that
Beck Depression Inventory (BDI) could be withdrawn , reducing in this way, the quantity
of information, making its articulation in the analysis and conclusions sections easier.
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APPENDIX A
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Associação Psiquiátrica Americana (2000)
Critérios de diagnóstico de Perturbação de Identidade de Género (DSM IV-TR)
A. Uma forte e persistente identificação com o género oposto (não meramente um
desejo de obter quaisquer vantagens culturais percebidas pelo facto de ser do
sexo oposto).
Nas crianças a perturbação manifesta-se por quatro (ou mais) dos seguintes:
1. declarou repetidamente o desejo de ser, ou insistência de que é, do sexo
oposto;
2. nos meninos, preferência pelo uso de roupas do género oposto ou
simulação de trajes femininos; nas meninas insistência em usar apenas
roupas estereotipadamente masculinas;
3. preferências intensas e persistentes por papeis do sexo oposto em
brincadeiras de faz-de-conta, ou fantasias persistentes acerca de ser do sexo
oposto;
4. intenso desejo de participar em jogos e passatempos tipicamente do sexo
oposto;
5. forte preferência por companheiros do sexo oposto.
Nos adolescentes e adultos a perturbação manifesta-se por sintomas tais como um
desejo declarado de ser do sexo oposto, fazer-se passar frequentemente por alguém, do
sexo oposto, desejo de viver ou de ser tratado como alguém do sexo oposto, ou a
convicção de ter os sentimentos e reacções típicas do sexo oposto.
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B. Desconforto persistente com o seu sexo ou sentimento de inadequação no
papel de género desse sexo.
Nas crianças a perturbação manifesta-se por qualquer das seguintes formas: nos
meninos, afirmação de que o seu pénis ou testículos são repulsivos ou vão
desaparecer, ou declaração de que seria melhor não ter pénis, ou aversão a
brincadeiras rudes e rejeição a brinquedos, jogos ou actividades estereotipadamente
masculinos; nas meninas, rejeição a urinar sentada, afirmação de que desenvolverá um
pénis, ou afirmação de que não deseja desenvolver seios ou menstruar ou acentuada
aversão a roupas caracteristicamente femininas.
Nos adolescentes e adultos a perturbação manifesta-se por sintomas tais como a
preocupação em libertar-se das características sexuais primárias ou secundárias (p.ex.,
pedir terapia hormonal, cirurgia ou outros procedimentos para alterar fisicamente as
características sexuais com o objectivo de simular o sexo oposto) ou a crença de ter
nascido com o sexo errado.
C. A perturbação não é concomitante a uma condição intersexual física.
D. A perturbação causa sofrimento clinicamente significativo ou prejuízo no
funcionamento social ou ocupacional ou em outras áreas importantes da vida
do indivíduo.
Codificar com base na idade actual:
F64.2 Perturbação de Identidade de Género em Crianças [302.6]
F64.0 Perturbação de Identidade de Género em Adolescentes ou Adultos [302.85]
Especificar se (para indivíduos sexualmente maduros):
Atracção sexual por homens
Atracção sexual por mulheres
Atracção sexual por ambos os sexos
Ausência de atracção sexual por quaisquer dos sexos
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Perturbação da Identidade de Género Sem Outra Especificação onde são
abrangidas categorias não classificáveis como uma Perturbação de Identidade de Género
específica. Nomeadamente, incluem-se:
i. estados intersexuais (p. ex., síndrome de insensibilidade aos
androgénios ou hiperplasia adrenal congénita) e disforia concomitante
quanto ao género;
ii. comportamento transvéstico transitório, relacionado ao stresse;
iii. preocupação persistente com a castração ou penectomia, sem um
desejo de adquirir as características sexuais do género oposto.
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APPENDIX B
- 253 -
Organização Mundial de Saúde (1997)
Para que se atribua o diagnóstico de Transexualismo é necessário que o indivíduo
apresente:
i. um desejo de viver como um membro do sexo oposto, usualmente
acompanhado por uma sensação de desconforto ou impropriedade do seu
próprio sexo anatómico; e
ii. um desejo de se submeter a tratamento hormonal e cirurgia para tornar
o seu corpo tão congruente quanto possível com o seu sexo preferido.
Para que o diagnóstico esteja correcto, a identidade transexual deve ter estado
persistentemente presente por pelo menos dois anos e não deve ser um sintoma de outro
transtorno mental, tal como a esquizofrenia, nem estar associado a uma anormalidade
cromossómica.
Para que o diagnóstico de Transvestismo de Duplo Papel se verifique, é
necessário que:
i. o indivíduo use roupas do sexo oposto para experimentar
temporariamente ser membro do sexo oposto;
ii. não haja motivação sexual para essa troca de roupa (o que o distingue
do transvestismo fetichista);
iii. o indivíduo não deseje uma mudança permanente para o sexo oposto.
Usualmente os Transtornos de Identidade Sexual na Infância manifestam-se
inicialmente durante a primeira infância e caracterizam-se por:
i. uma angústia persistente e intensa em relação ao sexo designado e o
desejo de ser, ou insistência de que é do outro sexo;
ii. preocupação persistente com a vestimenta e / ou actividades do sexo
oposto e / ou repúdio pelo próprio sexo.
- 254 -
Especificamente para as meninas:
i. apresenta angústia intensa e persistente por ser uma menina e tem um
desejo declarado de ser um menino ou insiste que ela é um menino;
ii. qualquer um dos seguintes critérios deve ser presente:
aversão marcante e persistente à vestimenta feminina e insistência em
usar vestimentas tipicamente masculinas;
repúdio persistente a estruturas anatómicas femininas, como
evidenciado por pelo menos um dos seguintes: uma assertiva de que ela
tem ou irá crescer um pénis; rejeição a urinar na posição sentada;
assertiva de que ela não quer que cresçam os seios ou ter a menstruação.
Especificamente para os meninos:
i. apresenta angústia persistente e intensa por ser um menino e tem um desejo
declarado de ser uma menina ou, mais raramente, insiste que ele é uma
menina;
ii. qualquer um dos seguintes critérios deve estar presente:
preocupação com actividades tipicamente femininas, demonstrada por
uma preferência por roupas ou imitação dos trajes femininos ou por um
desejo intenso de participar em jogos e passatempos de meninas e
rejeição de brinquedos, jogos e actividades tipicamente masculinas;
repúdio persistente a estruturas anatómicas masculinas, como indicado
por pelo menos uma das seguintes assertivas repetidas: que ele crescerá
para tornar-se uma mulher (não meramente um papel); que o seu pénis ou
testículos são repugnantes ou desaparecerão; que seria melhor não ter
pénis ou testículos.
- 255 -
APPENDIX C
- 256 -
APPENDIX C – I
Gender Identity Disorder
Pre and Post Surgery Changes - Personality Profile, Psychopathology and Social
Adjustment - a Comparative Study
by
Iris Monteiro
The American Academy of Clinical Sexologists (AACS)
Declaração de Consentimento Informado
Declaro que tomei conhecimento que os dados por mim preenchidos podem ser utilizados para fins de
investigação desde que seja salvaguardado o anonimato.
____________________
(rubrica)
Lisboa, ___ de __________ de 2010
- 257 -
APPENDIX C – II
Entrevista PIG
Dados Pessoais
n=
Nome: ___________________________________________________________ Data ___ / ___ / _____
Sexo: F M
Idade: _____ anos
Data de nascimento: _____ / _____ / _____
Habilitações Literárias (GRAFFAR):
Ensino Universitário/Equivalente (+12 Anos escolaridade) Bacharelato
Ensino Médio/Técnico Superior (até 10-12 Anos escolaridade)
Ensino Médio/Técnico Inferior (até 8-9 Anos de escolaridade)
Ensino Primário completo
Ensino Primário incompleto/nulo
Licenciatura
Nível Profissional (GRAFFAR):
Nível 1
Nível 2
Nível 3
Nível 4
Nível 5
Profissão: _______________
Situação Profissional:
Activo
Activo/Baixa
Desempregado
Reformado
Estudante
Outra
Nacionalidade: _____________________
Naturalidade: ______________________
Residência actual: ______________________________________________________________________
Hábitos Tóxicos
Álcool ___________________
Droga ___________________
Tabaco __________________
Outros __________________
Estado Civil:
Solteiro
Casado
Viúvo
Separado
- 258 Uniões Anteriores:
Não
Sim
Se sim, quantas? _____
Actualmente, quantos parceiros tem?
Nenhum
Um
Dois
Três ou mais
Relacionamento estável:
Não
Sim
Se sim, especifique:
Existência de filhos:
Não
Sim
Se sim, quantos? _____ Especificado ___________________
menos de 1 ano
entre 1 a 3 anos
mais de 3 anos
Dados Familiares
Núcleo Familiar ________________________________________________________________________
(vive com...)
Pais:
Estado Civil ____________________________________________________________________
Idade _________________________________________________________________________
Profissão ______________________________________________________________________
Irmãos:
Nº de irmãos ___________________________________________________________________
Posição na fratria _______________________________________________________________
Dados Clínicos
Diagnóstico Perturbação da Identidade de Género
Não
Sim
Fase do Processo Reatribuição Sexual ______________________________________________________
PRS Avaliação / PRS T. Endo / O.M. / PRS C.R.S. / PRS P. Judicial / Interrupção do PRS (especificar em que
fase)
Data inicio PRS _____ / _____ / ________
Data término PRS _____ / _____ / ________
- 259 -
Acomp. Psiquiátrico:
Não
Sim
Medicação
Não
Sim
Se sim, especifique? ________________________________________
(Diagnóstico / Data inicio / Duração)
Se sim, especifique? ________________________________________
(Incluir medicação Terapêutica Hormonal/ Psicotrópicos)
Co-morbilidades:
_____________________________________________________________________________________
_____________________________________________________________________________________
Intervenção Psicoterapêutica Especificada:
_____________________________________________________________________________________
_____________________________________________________________________________________
- 260 -
APPENDIX C – III
SCL – 90 – R (Derogatis, 1977, 1993)
(Tradução e Adaptação de Ana Galhardo, Paula Castilho e José Pinto Gouveia, 1999)
Nome ____________________________________________________________ Data _____________
Instruções: A seguir encontra-se uma lista de problemas e queixas médicas que algumas pessoas
costumam ter. Leia cuidadosamente cada questão e assinale aquelas que nos últimos 2 anos lhe têm dado
cuidados ou preocupações. Não existem respostas “certas” ou “erradas”, nem respostas para dar uma boa
impressão: são apenas problemas ou queixas que cada um sentiu ou sente e devem ser consideradas como
tal. Estas respostas estão sujeitas a segredo médico. Por favor, não deixe nenhuma questão em branco.
Assinale com uma cruz o número que corresponde à sua resposta:
0 – Nunca
1 – Pouco
2 – Moderadamente
3 – Bastante
4 -Extremamente
Em que medida sofreu das seguintes queixas?
0
1. Dores de cabeça
2. Nervosismo ou sentir-se a tremer por dentro
3. Repetidos pensamentos desagradáveis que não lhe saiem da cabeça
4. Desmaios ou tonturas
5. Perda do interesse ou do prazer sexual
6. Ter vontade de criticar os outros, mas não o fazer
7. Ter a ideia de que alguém pode controlar os seus pensamentos
8. Sentir que os outros são os culpados pela maior parte dos seus problemas
9. Dificuldade em lembrar-se das coisas
10. Preocupar-se com o desleixo ou com a falta de cuidado
11. Sentir-se facilmente aborrecido ou irritado
12. Dores no coração ou no peito
13. Sentir medo em espaços abertos na rua
14. Sentir uma diminuição da energia ou lentidão
15. Pensamentos de acabar com a vida
16. Ouvir vozes que as outras pessoas não ouvem
17. Tremor
18. Sentir que não pode confiar na maioria das pessoas
19. Falta de apetite
20. Chorar facilmente
21. Sentir-se tímido ou nervoso compessoas do sexo oposto
22. Sentir-se preso ou apanhado
23. Medo súbito sem razão
24. Acessos de cólera que não consegue controlar
25. Sentir medo de sair de casa sozinho
26. Culpar-se a si mesmo pelo que acontece
27. Dores no fundo das costas
28. Sentir um bloqueio ao fazer as coisas
29. Sentir-se só
30. Sentir-se triste
31. Preocupar-se demasiado com as coisas
32. Sentir falta de interesse pelas coisas
33. Sentir-se atemorizado
34. Sentir-se magoado
35. Sentir que as outras pessoas conhecem os seus pensamentos
1
2
3
4
- 261 -
0
36. Sentir que os outros são antipáticos ou não o compreendem
37. Sentir que as pessoas não são suas amigas ou não gostam de si
38. Fazer as coisas muito lentamente para ter a certeza de são bem feitas
39. Palpitações ou o coração a bater muito
40. Náuseas ou enjoos no estômago
41. Sentir-se inferior aos outros
42. Dores musculares
43. Sentir que os outros o estão a observar ou a falar de si
44. Dificuldade em adormecer
45. Ter que verificar várias vezes o que faz
46. Dificuldade em tomar decisões
47. Sentir medo de viajar de autocarro, metro ou comboio
48. Dificuldade em respirar, sensação de falta de ar
49. Ataques súbitos de calor ou frio
50. Ter que evitar certas coisas, locais ou actividades porque estes o assustam
51. Momentos com “brancas”
52. Entorpecimento ou formigueiro em certas partes do corpo
53. Um aperto ou nó na garganta
54. Sentir-se sem esperança no futuro
55. Dificuldade em concentrar-se
56. Sensação de faqueza em certas partes do corpo
57. Sentir-se tenso ou agitado
58. Sentir os braços ou as pernas pesados
59. Pensamentos acerca da morte ou de que vai morrer
60. Comer demais
61. Sentir desconforto quando as pessoas estão a olhar ou a falar de si
62. Ter pensamentos que não são seus
63. Ter impulsos para bater, injuriar ou magoar alguém
64. Acordar muito cedo de manhã
65. Ter que repetir coisas como tocar, contar ou lavar
66. Sono agitado ou perturbado
67. Ter impulsos para partir, estragar ou esmagar coisas
68. Ter ideias ou crenças que os outros não partilham
69. Sentir-se muito auto-consciente com os outros, na presença dos outros
70. Sentir desconforto em multidões, como por exemplo ao fazer compras ou ir
ao cinema
71. Sentir que tudo é uma maçada, um esforço
72. Momentos de terror ou pânico
73. Sentir desconforto em comer ou bebr em público
74. Envolver-se em discussões frequentes
75. Sentir-se nervoso quando está sozinho
76. Achar que os outros não dão crédito às suas realizações
77. Sentir-se sozinho mesmo na presença de outras pessoas
78. Sentir-se tão agitado que não consegue estar quieto
79. Sentir que é uma pessoa sem valor
80. Sentir que alguma coisa má lhe vai acontecer
81. Gritar ou atirar coisas
82. Sentir medo de desmaiar em público
83. Sentir que as pessoas se irão aproveitar de si, se as deixar
84. Ter pensamentos sexuais que o perturbam muito
85. Ter a ideia de que deve ser punido pelos seus pecados
86. Pensamentos ou imagens de uma natureza assustadora
87. Ter a ideia de que alguma coisa séria se passa de errado no seu corpo
88. Nunca se sentir próximo de outra pessoa
89. Sentimentos de culpa
90. Ter a ideia de que se passa algo de errado com a sua mente
1
2
3
4
- 262 -
APPENDIX C – IV
I. D. BECK (Beck, 1961)
Nome _____________________________________________________________ Data ____________
Este questionário é constituído por vários grupos de afirmações. Assinale a resposta que melhor descreve
a forma como hoje se sente.
A.
Não me sinto triste
Ando “neura” ou triste
Sinto-me “neura” ou triste todo o tempo e não consigo evitá-lo
Estou tão triste ou infeliz que se torna penoso para mim
Sinto-me tão triste ou infeliz que não consigo mais suportar
B. Não estou demasiado pessimista, nem me sinto desencorajado em relação ao futuro
Sinto-me com medo do futuro
Sinto que não tenho nada a esperar do que surja no futuro
Creio que nunca conseguirei resolver os meus problemas
Não tenho qualquer esperança no futuro e penso que a minha situação não pode melhorar
C. Não tenho a sensação de ter fracassado
Sinto que tive mais fracassos que a maioria das pessoas
Sinto que realizei muito pouca coisa que tivesse valor ou significado
Quando analiso a minha vida passada, tudo o que vejo são uma quantidade de fracassos
Sinto-me completamente falhado como pessoa (pai, mãe, marido, mulher)
D. Não me sinto descontente com nada em especial
Sinto-me aborrecido a maior parte do tempo
Não tenho satisfação com as coisas que me alegravam antigamente
Nunca mais consigo obter satisfação seja com o que for
Sinto-me descontente com tudo
E. Não me sinto culpado de nada em particular
Sinto grande parte do tempo, que sou mau, ou que não tenho qualquer valor
Sinto-me bastante culpado
Agora, sinto, permanentemente, que sou mau, ou que não tenho qualquer valor
Considero que sou muito mau e não valho absolutamente nada
F. Não sinto que esteja a ser vítima de qualquer castigo
Tenho o pressentimento de que me pode acontecer alguma coisa de mal
Sinto que estou a ser castigado ou que em breve serei castigado
Sinto que mereço ser castigado
Quero ser castigado
- 263 G.
Não me sinto descontente comigo
Estou desiludido comigo mesmo
Não gosto de mim
Estou bastante desgostoso comigo
Odeio-me
H. Não sinto que seja pior do que qualquer outra pessoa
Critico-me a mim mesmo, pelas minhas fraquezas ou erros
Culpo-me das minhas próprias faltas
Acuso-me por tudo de mal que acontece
I.
Não tenho qualquer idéia de fazer mal a mim mesmo
Tenho ideias de pôr termo à vida, mas não sou capaz de as concretizar
Sinto que seria melhor morrer
Creio que seria melhor para a família se eu morresse
Tenho planos concretos sobre a forma de como hei-de pôr termo à vida
Matar-me-ia se tivesse oportunidade
J.
Actualmente não choro mais do que o costume
Choro mais agora do que costumava
Actualmente passo o tempo a chorar e não consigo parar de fazê-lo
Costumava ser capaz de chorar, mas agora nem sequer consigo mesmo quando tenho vontade
K. Não ando agora mais irritado do que o costume
Fico aborrecido ou irritado mais facilmente do que costumava
Sinto-me permanentemente irritado
Já não consigo ficar irritado por coisas que me irritavam antigamente
L. Não perdi o interesse que tinha nas outras pessoas
Actualmente sinto menos interesse pelos outros do que costumava ter
Perdi quase todo o interesse pelas outras pessoas, sentindo pouca simpatia por elas
Perdi por completo o interesse pelas outras pessoas, não me importando absolutamente nada
M. Sou capaz de tomar decisões tão bem como antigamente
Actualmente sinto-me menos seguro de mim mesmo e procuro evitar tomar decisões
Não sou capaz de tomar decisões sem a ajuda das outras pessoas
Sinto-me completamente incapaz de tomar qualquer decisão
N. Não acho que tenha pior aspecto do que o costume
Estou aborrecido porque estou a parecer velho ou pouco atraente
Sinto que se deram modificações permanentes na minha aparência que me tornam pouco atraente
Sinto que sou feio ou que tenho um aspecto repulsivo
- 264 O. Sou capaz de trabalhar tão bem como antigamente
Agora preciso de um esforço maior do que dantes para começar a trabalhar
Não consigo trabalhar tão bem como costumava
Tenho de dispender um grande esforço para fazer seja o que for
Sinto-me incapaz de realizar qualquer trabalho, por mais pequeno que seja
P.
Consigo dormir tão bem como dantes
Acordo mais cansado de manhã do que era habitual
Acordo cerca de 1 – 2 horas mais cedo do que o costume e custa-me voltar a adormecer
Acordo todos os dias mais cedo do que o costume e não durmo mais do que 5 horas
Q. Não me sinto mais cansado do que é habitual
Fico cansado com mais facilidade do que antigamente
Fico cansado quando faço seja o que for
Sinto-me tão cansado que sou incapaz de fazer o que quer que seja
R. O meu apetite é o mesmo de sempre
O meu apetite não é tão bom como costumava ser
Actualmente o meu apetite está muito pior do que antigamente
Perdi completamente todo o apetite que tinha
S. Não tenho perdido muito peso, se é que ultimamente perdi algum
Perdi mais de 2,5 quilos de peso
Perdi mais de 5 quilos de peso
Perdi mais de 7,5 quilos de peso
T. A minha saúde não me preocupa mais do que o habitual
Sinto-me preocupado com dores ou sofrimentos, ou má disposição do estômago, ou prisão de ventre
Ou ainda outras sensações físicas desagradáveis, no meu corpo
Estou tão preocupado com a maneira como me sinto ou com aquilo que sinto, que se torna difícil
pensar noutra coisa
Encontro-me totalmente preocupado pela maneira como me sinto
U. Não notei qualquer mudança recente no meu interesse pela vida sexual
Encontro-me menos interessado pela vida sexual do que costumava estar
Actualmente sinto-me muito menos interessado pela vida sexual
Perdi completamente o interesse pela vida sexual
- 265 -
APPENDIX C – V
Questionário da Vida Sócio-Familiar
(Cooper, Osborn, Gath & Feggeter, 1982)
Nome ______________________________________________________________ Data ____________
Queremos saber como tem passado nas duas últimas semanas.
Gostaríamos que respondesse a algumas perguntas sobre o seu emprego, os seus tempos
livres e a sua vida familiar. Por favor, responda às perguntas que estão nas páginas seguintes
assinalando a resposta que melhor se lhe aplicar.
EMPREGO
As perguntas nesta página destinam-se a saber como tem estado no seu emprego (a tempo inteiro ou a
tempo parcial). Se não está empregado(a) não responda a estas perguntas e continue com a página
seguinte.
Ao longo das duas últimas semanas:
1. Tem faltado ao emprego?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
2. Tem estado a desempenhar bem as suas tarefas?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
3. Tem sentido vergonha da maneira como faz o seu trabalho?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
4. Tem entrado em discussão ou conflitos com as pessoas no emprego?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
5. Tem-se sentido preocupado(a), incomodado(a) ou perturbado(a) no emprego?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
6. Tem sentido interesse pelo seu trabalho?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
- 266 TAREFAS DOMÉSTICAS
As seguintes perguntas são sobre as suas tarefas domésticas.
Ao longo das duas últimas semanas:
7. Tem feito diariamente as tarefas domésticas?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
Ocasionalmente__
Nunca__
8. Tem desempenhado bem os seus trabalhos domésticos?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
9. Tem sentido vergonha da maneira como faz as suas tarefas domésticas?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
10. Tem-se exaltado e discutido com vendedores ou vizinhos?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
11. Tem-se sentido incomodado(a), preocupado(a) ou perturbado(a) enquanto faz as tarefas domésticas?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
12. Tem achado as tarefas domésticas maçadoras, desagradáveis ou um peso para si?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
OCUPAÇÃO DOS TEMPOS LIVRES
As seguintes perguntas têm a ver com as suas amizades e destinam-se às relações com os seus amigos
e à maneira como ocupa o seu tempo livre.
Ao longo das duas últimas semanas:
13. Tem contactado com alguns dos seus amigos?
Com muita frequência__
Frequentemente__
Algumas vezes__
Muito raramente__
Nunca__
14. Tem conseguido falar abertamente, com os seus amigos, sobre os seus problemas?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
15. Tem contactado com os seus amigos? (por ex. fazer e receber visitas, saídas, encontros)
Com muita frequência__
Frequentemente__
Algumas vezes__
Muito raramente__
Nunca__
16. Ocupou os seus tempos livres com coisas que o(a) interessam?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
17. Tem-se exaltado ou discutido com os seus amigos?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
- 267 18. Tem-se sentido magoado(a) ou ofendido(a) pelos seus amigos?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
19. Tem-se sentido pouco à vontade, tenso(a) ou envergonhado(a) na presença dos outros?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
20. Tem-se sentido só e com desejo de companhia?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
21. Tem-se sentido aborrecido(a) quando tem tempo livre?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
FAMILIA ALARGADA
As seguintes perguntas debruçam-se sobre o seu relacionamento com a sua família (os seus pais,
irmãos, sogros ou filhos que não vivem consigo). Não inclui o seu cônjuge, nem os filhos que vivem
consigo.
Ao longo das duas últimas semanas:
22. Tem-se exaltado ou discutido com alguém dos seus familiares?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
23. Tem feito algum esforço para se manter em contacto com os seus familiares?
Com muita frequência__
Frequentemente__
Algumas vezes__
Muito raramente__
Nunca__
24. Tem conseguido falar abertamente, sobre os seus sentimentos, com os seus familiares?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
25. Tem estado dependente dos seus familiares porque estes o(a) aconselham e ajudam?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
26. Tem-se preocupado demasiadamente com o que poderia acontecer aos seus familiares?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
27. Sente que tem desiludido alguns dos seus familiares?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
28. Sente-se desiludido com algum dos seus familiares?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
- 268 RELAÇÃO CONJUGAL
As seguintes perguntas são sobre o seu relacionamento com o seu cônjuge. Se não mantém uma relação
conjugal deixe esta secção e continue com a próxima.
Ao longo das duas últimas semanas:
29. Têm-se exaltado ou discutido um com o outro?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
30. Tem conseguido discutir os seus sentimentos e problemas com o(a) seu (sua) parceiro(a)?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
31. A maioria das decisões domésticas têm sido tomadas por si?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
32. Quando há desacordo tem tendência para ceder?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
33. Tem partilhado as responsabilidades em relação às questões práticas que surgiram?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
34. Tem sido obrigado(a) a depender da ajuda do(a) seu(sua) parceiro(a)?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
35. Tem sido afectuoso(a) com o(a) seu(sua) parceiro(a)?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
36. Com que frequência tem tido relações sexuais com o(a) seu(sua) parceiro(a)?
Quatro vezes ou mais__
Três vezes__
Duas vezes__
Uma vez__
Nunca__
37. Tem sentido algum problema durante as relações sexuais? (por ex. dor ou dificuldade em atingir o
orgasmo)
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
38. Tem sentido prazer no relacionamento sexual?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
- 269 FILHOS
As seguintes perguntas são sobre o seu relacionamento com os seus filhos. Se os seus filhos já não
vivem em casa, não responda a estas perguntas e continue com a próxima secção.
Ao longo das duas últimas semanas:
39. Tem sentido interesse pelas actividades dos seus filhos? (por ex. escola, amigos, etc)
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
Ocasionalmente__
Nunca__
40. Tem conseguido ouvir e falar com os seus filhos?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
41. Tem gritado ou discutido com os seus filhos?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
42. Tem-se sentido afectuoso(a) com os seus filhos?
Sempre__
A maior parte do tempo__
Cerca de metade do tempo__
Ocasionalmente__
Nunca__
FAMILIA NUCLEAR
As seguintes perguntas debruçam-se sobre o seu relacionamento com a sua família imediata, isto é, o(a)
seu(sua) parceiro(a) e os seus filhos que vivem consigo. Se não se encontra nesta situação, por favor,
não responda.
Ao longo das duas últimas semanas:
43. Tem-se preocupado desnecessariamente com possíveis desgraças que acontecem à sua família?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
44. Tem sentido que alguma vez não fez o suficiente pela sua família?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
A maior parte do tempo__
Sempre__
A maior parte do tempo__
Sempre__
45. Tem sentido que a sua família não faz o suficiente por si?
Nunca__
Ocasionalmente__
Cerca de metade do tempo__
- 270 -
APPENDIX C – VI
Data ____________
MCMI – II
Inventário Clínico Multiaxial de Millon
(Millon, 1987)
Instruções
1. As páginas seguintes contêm uma série de afirmações que as pessoas utilizam para se
descreverem e que o ajudarão a caracterizar os seus sentimentos e atitudes. Tente ser
o mais sincero possível nas escolhas que fizer. Os resultados ajudarão o seu terapeuta
a compreender os seus problemas e a planear a intervenção.
2. Não se preocupe se algumas frases lhe parecem pouco usuais. Elas estão incluídas no
questionário para descreverem pessoas com problemas variados. Quando concordar
com a afirmação ou decidir que esta o descreve, marque um V (exemplo – (V) F). Se
discordar da afirmação ou decidir que ela não o descreve, marque F (exemplo – V (F)).
Tente responder a todas as afirmações mesmo que não esteja seguro da sua escolha.
Se pensou suficientemente bem e mesmo assim não se consegue decidir, marque F.
3. Não há limite de tempo para preencher este questionário, mas é preferível que
responda o mais rapidamente que lhe seja possível e confortável.
4. Os resultados deste questionário são estritamente confidenciais.
Dados Pessoais
Nome:
_______________________________________________________________
Sexo:M
F
Idade:____anos Data Nascimento:___/___/___Estado Civil:
__________
Áreas Problemáticas actuais
Marital ou Familiar
Profissional ou escolar
Solidão
Temperamento
Auto-confiança
Doença ou cansaço
Álcool
Drogas
Problemas Sexuais
Comportamento anti-social
Outros
- 271 -
1
Sigo sempre as minhas ideias em vez de fazer aquilo que os outros esperam de mim.
V
F
2
Sempre me senti melhor a fazer as coisas calmamente sozinho do que com outras
pessoas.
V
F
3
Falar com as outras pessoas tem sido quase sempre difícil e penoso para mim.
V
F
4
Acredito ter força de vontade e ser determinado em tudo aquilo que faço.
V
F
5
Nas últimas semanas começo a chorar quando a mais pequena coisa corre mal.
V
F
6
Algumas pessoas acham-me presunçoso e centrado em mim próprio.
V
F
7
Quando era adolescente tinha muitos problemas por causa do meu mau
comportamento na escola.
V
F
8
Sinto sempre que não sou desejado num grupo.
V
F
9
Critico frequentemente com veemência quem me aborrece.
V
F
10
Sinto-me satisfeito por ser um seguidor de outros.
V
F
11
Gosto de fazer tantas coisas diferentes que não consigo decidir o que fazer primeiro.
V
F
12
Por vezes posso ser muito duro e mau nas relações com a minha família.
V
F
13
Tenho pouco interesse em fazer amigos.
V
F
14
Penso que sou uma pessoa muito sociável e que gosta muito de se dar com os outros.
V
F
15
Sei que sou uma pessoa superior, por isso não me preocupo com o que as outras
pessoas pensam.
V
F
16
As pessoas nunca me deram crédito suficiente pelas coisas que eu tenho feito.
V
F
17
Tenho um problema com a bebida que tenho tentado acabar sem sucesso.
V
F
18
Ultimamente, sinto “borboletas no estômago” e fico com suores frios.
V
F
19
Tentei sempre expor-me pouco durante as actividades sociais.
V
F
20
Farei sempre coisas pelo simples facto de poderem ser divertidas.
V
F
V
F
V
F
21
22
Fico muito aborrecido com as pessoas que nunca parecem ser capazes de fazer nada
bem.
Se a minha família me pressiona, é provável que me sinta zangado e resista a fazer o
que eles querem.
23
Sinto frequentemente que devo ser punido pelas coisas que fiz.
V
F
24
As pessoas gozam comigo nas minhas costas, comentando a forma como me comporto
ou apareço.
V
F
25
As outras pessoas parecem mais seguras do que eu sobre quem são e o que querem.
V
F
26
Tenho tendência para desatar a chorar ou ter ataques de fúria por razões que
desconheço.
V
F
27
Comecei a sentir-me sozinho e vazio há cerca de um ano ou dois atrás.
V
F
28
Tenho tendência a ser dramático.
V
F
29
Tenho dificuldade em manter o equilíbrio quando ando.
V
F
30
Gosto de competição intensa.
V
F
31
Quando entro em crise procuro rapidamente alguém que me ajude.
V
F
32
Protejo-me de problemas nunca deixando as outras pessoas saberem muito a meu
respeito.
V
F
33
Sinto-me fraco e cansado a maior parte do tempo.
V
F
- 272 -
34
As outras pessoas ficam mais zangadas com coisas aborrecidas do que eu.
V
F
35
O vício da droga sempre me meteu numa série de problemas no passado.
V
F
36
Ultimamente, dou comigo a chorar sem qualquer razão.
V
F
37
Acho que sou uma pessoa especial que merece atenção especial dos outros.
V
F
38
Nunca me deixo enganar por pessoas que dizem que precisam de ajuda.
V
F
39
Uma forma certa de tornar o mundo pacífico é melhorando a moral das pessoas.
V
F
40
No passado envolvi-me sexualmente com muitas pessoas que não significavam muito
para mim.
V
F
41
Acho difícil simpatizar com pessoas que estão sempre inseguras acerca das coisas.
V
F
42
Sou uma pessoa muito concordante e submissa.
V
F
43
O meu mau génio sempre foi a causa principal dos meus problemas.
V
F
44
Não me importo de intimidar os outros para conseguir que eles façam o que eu quero.
V
F
45
Nos últimos anos até a mais pequena das coisas parecia deprimir-me.
V
F
46
O meu desejo de conseguir fazer as coisas perfeitas, atrasa frequentemente o meu
trabalho.
V
F
47
Sou tão sossegado e reservado que a maioria das pessoas nem nota que eu existo.
V
F
48
Gosto de namoriscar com membros do sexo oposto.
V
F
49
Sou uma pessoa passiva e medrosa.
V
F
50
Sou uma pessoa instável, que muda constantemente de ideias e sentimentos.
V
F
51
Sinto-me muito tensa quando penso nos acontecimentos do dia.
V
F
52
Beber álcool nunca me causou problemas sérios no trabalho.
V
F
53
Ultimamente sinto não ter forças, mesmo pela manhã.
V
F
54
Comecei a sentir-me um falhado há alguns anos atrás.
V
F
55
Fico ressentido com as pessoas que têm a mania que conseguem sempre fazer as
coisas melhor do que eu.
V
F
56
Sempre tive um medo terrível de perder o amor das pessoas de quem mais preciso.
V
F
57
Deixo com facilidade que as pessoas se aproveitem de mim.
V
F
58
Ultimamente, tenho vontade de partir coisas.
V
F
59
Ultimamente, tenho pensado seriamente em acabar comigo.
V
F
60
Estou sempre a tentar fazer novos amigos e a conhecer pessoas novas.
V
F
61
Controlo bastante bem as minhas finanças para estar preparado para qualquer
eventualidade.
V
F
62
Estive na primeira página de várias revistas no ano passado.
V
F
63
Poucas pessoas gostam de mim.
V
F
64
Se alguém me criticasse por ter feito um erro, rapidamente apontaria alguns dos erros
dessa pessoa.
V
F
65
Algumas pessoas dizem que eu gosto de sofrer.
V
F
66
Expresso frequentemente os meus sentimentos de raiva e depois sinto-me
terrivelmente culpado por isso.
V
F
67
Ultimamente, sinto-me agitado e sob grande tensão, mas não sei porquê.
V
F
- 273 -
68
Perco frequentemente a capacidade de sentir quaisquer sensações em partes do meu
corpo.
V
F
69
Acredito que existem pessoas que usam telepatia para influenciar a minha vida.
V
F
70
Tomar as chamadas drogas ilegais pode ser insensato, mas no passado eu achei que
precisava delas.
V
F
71
Sinto-me sempre cansado.
V
F
72
Parece que não consigo dormir e acordo tão cansado como quando fui para a cama.
V
F
73
Tenho feito uma série de coisas estúpidas, por impulso, que acabaram por me causar
muitos problemas.
V
F
74
Nunca perdoo um insulto, nem esqueço um embaraço que alguém me causou.
V
F
75
Devemos respeitar as gerações anteriores e não pensarmos que sabemos mais do que
elas.
V
F
76
Presentemente, sinto-me terrivelmente deprimido e triste a maior parte do tempo.
V
F
77
Sou do tipo de pessoas de quem os outros se aproveitam.
V
F
78
Tento sempre agradar aos outros mesmo quando não gosto deles.
V
F
79
Há vários anos que me ocorrem sérios pensamentos de suicídio.
V
F
80
Descubro com facilidade como as pessoas estão a tentar causar-me problemas.
V
F
81
Sempre tive menos interesse pelo sexo do que a maioria das pessoas.
V
F
82
Não consigo compreender porquê, mas pareço gostar de magoar as pessoas que amo.
V
F
83
Há muito tempo, decidi ser melhor ter pouco a ver com as pessoas.
V
F
V
F
V
F
84
85
Estou disposto a lutar até à morte para não deixar que ninguém me roube a minha autodeterminação.
Desde criança que sempre tive de estar alerta face a pessoas que tentavam enganarme.
86
Quando as coisas se tornam aborrecidas gosto de encontrar algo excitante.
V
F
87
Tenho um problema com o álcool que tem criado problemas, para mim e para a minha
família,
V
F
88
Se alguém deseja fazer algo que exige grande paciência, deve pedir-me a mim.
V
F
89
Sou provavelmente o pensador mais criativo de entre as pessoas que conheço.
V
F
90
Não vi um único carro nos últimos 10 anos.
V
F
91
Não vejo nada de errado em usar as pessoas para obter aquilo que quero.
V
F
92
A punição nunca me impediu de fazer aquilo que queria.
V
F
93
Há muitas ocasiões em que, sem razão aparente, me sinto muito alegre e cheio de
entusiasmo.
V
F
94
Quando era adolescente fugi de casa, pelo menos uma vez.
V
F
95
Digo muitas vezes coisas que me arrependo de ter dito.
V
F
96
Nas últimas semanas sinto-me exausto, sem razão especial.
V
F
97
Desde algum tempo que me tenho sentido culpado por já não conseguir fazer bem as
coisas.
V
F
98
As ideias circulam no meu pensamento sem parar, e não se vão embora.
V
F
99
Tornei-me bastante desanimado e triste acerca da vida, nos últimos um ou dois anos.
V
F
100
Muitas pessoas têm vindo a espiar a minha vida privada, há anos.
V
F
- 274 -
101
Não sei porquê, mas às vezes digo coisas cruéis só para fazer os outros infelizes.
V
F
102
Detesto ou tenho medo da maioria das pessoas.
V
F
V
F
V
F
103
104
Expresso abertamente a minha opinião acerca das coisas, sem me importar com o que
os outros possam pensar.
Quando alguma figura de autoridade insiste para que eu faça algo, é provável que não
o faça ou que o faça mal de propósito.
105
O meu hábito de abuso de drogas levou-me a faltar ao trabalho no passado.
V
F
106
Estou sempre disposto a ceder em favor de outros para evitar desacordos.
V
F
107
Estou frequentemente irritado e rabugento.
V
F
108
Já não tenho forças para ripostar.
V
F
109
Ultimamente, tenho que repetir as coisas vezes sem conta, sem razão aparente.
V
F
110
Penso frequentemente que não mereço as coisas boas que me acontecem.
V
F
111
Uso o meu charme para chamar a atenção das outras pessoas.
V
F
112
Quando estou sozinho sinto frequentemente a presença de outra pessoa que não pode
ser vista.
V
F
113
Sinto-me à deriva, sem saber para onde a vida vai.
V
F
114
Ultimamente tenho suado muito e sentindo-me muito tenso.
V
F
115
Às vezes sinto que devo fazer algo para me magoar a mim ou a outras pessoas.
V
F
116
Tenho sido injustamente punido pela lei, por crimes que nunca cometi.
V
F
117
Estive muito agitado nas últimas semanas.
V
F
118
Continuo a ter pensamentos estranhos dos quais gostava de me ver livre.
V
F
119
Tenho tido muita dificuldade para tentar controlar o impulso para beber em excesso.
V
F
120
A maioria das pessoas pensa que eu não valho nada.
V
F
121
Consigo ficar muito excitado sexualmente quando luto ou discuto com a pessoa que
amo.
V
F
122
Tenho sido capaz, ao longo dos anos, de manter o meu consumo de álcool no mínimo.
V
F
123
Sempre “testei” os outros para descobrir até que ponto é que eles são de confiança.
V
F
124
Mesmo quando estou acordado pareço não notar as pessoas que me rodeiam.
V
F
125
Tenho muita facilidade em fazer muitos amigos.
V
F
126
Tenho sempre que ter a certeza de que o meu trabalho está bem planeado e
organizado.
V
F
127
Frequentemente oiço as coisas tão bem, que isso me incomoda.
V
F
128
O meu humor parece mudar de dia para dia.
V
F
129
Não culpo ninguém que se aproveite de quem não se importa com isso.
V
F
130
Mudei de emprego mais de três vezes nos últimos dois anos.
V
F
131
Tenho muitas ideias que estão avançadas no tempo.
V
F
132
Há já algum tempo que me venho sentindo triste e não consigo sair deste estado.
V
F
133
Penso que é sempre melhor procurar ajuda para tudo aquilo que faço.
V
F
134
Zango-me frequentemente com as pessoas que fazem as coisas devagar.
V
F
- 275 -
135
136
Fico realmente chateado com as pessoas que esperam que eu faça aquilo que não
quero.
Nos últimos anos tenho-me sentido tão culpado que poderei fazer algo de terrível a mim
próprio.
V
F
V
F
137
Nunca me isolo quando estou numa festa.
V
F
138
Dizem-me que sou uma pessoa correcta e com sentido moral.
V
F
139
Por vezes fico confuso e sinto-me incomodado quando as pessoas são simpáticas para
mim.
V
F
140
O meu consumo das chamadas drogas ilegais tem levado a discussões familiares.
V
F
141
Fico muito apreensivo nas relações com o sexo oposto.
V
F
142
Há membros na minha família que dizem que eu sou egoísta e que só penso em mim.
V
F
143
Não me importo que as pessoas não se interessem por mim.
V
F
144
Francamente, minto com frequência para não ter chatices.
V
F
145
As pessoas podem mudar facilmente as minhas ideias mesmo que já esteja decidido.
V
F
146
Há pessoas que me tentaram “tramar” mas eu tenho força de vontade suficiente para os
neutralizar.
V
F
147
Os meus pais diziam-me com frequência que eu não prestava.
V
F
148
Faço frequentemente as pessoas zangarem-se, mandando nelas.
V
F
149
Tenho um grande respeito pelos que são hierarquicamente superiores.
V
F
150
Não tenho praticamente laços pessoais fortes com nenhuma pessoa.
V
F
151
As pessoas disseram no passado que eu fiquei demasiadamente interessado e
demasiadamente entusiasmado com demasiadas coisas.
V
F
152
Voei sobre o Atlântico trinta vezes no ano passado.
V
F
153
Acredito no ditado “deitar cedo e cedo erguer…”.
V
F
154
Mereço o sofrimento que tenho experimentado na minha vida.
V
F
155
Os meus sentimentos em relação às pessoas importantes da minha vida passam
frequentemente do amor ao ódio.
V
F
156
Os meus pais sempre discordaram um do outro.
V
F
157
Já me aconteceu beber dez ou mais bebidas sem ficar bêbado.
V
F
158
Nos grupos sociais fico quase sempre muito auto-consciente e tenso.
V
F
159
Eu tenho em grande conta as regras porque acho que são um bom guia a seguir.
V
F
160
Desde criança que tenho vindo a perder o contacto com a realidade.
V
F
161
Raramente sinto algo com intensidade.
V
F
162
Costumava realmente ser inquieto, viajando de lugar para lugar sem saber onde iria
parar.
V
F
163
Não suporto as pessoas que chegam atrasadas aos encontros.
V
F
V
F
V
F
164
165
Há pessoas velhacas que frequentemente tentam ficar com o crédito das coisas que fiz
ou pensei.
Fico muito irritado se as pessoas exigem que eu faça as coisas à maneira delas, e não
à minha.
166
Tenho capacidade para ter sucesso em quase tudo o que faço.
V
F
167
Ultimamente, tenho-me sentido a desfazer em pedaços.
V
F
- 276 -
168
Pareço encorajar as pessoas que amo a magoarem-me.
V
F
169
Nunca tive nenhum pêlo nem na cabeça nem no corpo.
V
F
170
Quando estou com outras pessoas gosto de ser o centro das atenções.
V
F
V
F
V
F
171
172
Pessoas pelas quais tive uma grande admiração inicialmente, acabaram por me
desapontar.
Sou do tipo de pessoas que é capaz de se dirigir a alguém e dar-lhe uma
descompostura.
173
Prefiro estar com pessoas que me protejam.
V
F
174
Houve muitos períodos na minha vida em que estava tão contente e gastei tanta
energia que me fui abaixo.
V
F
175
Tive dificuldades no passado em evitar o abuso de drogas ou álcool.
V
F
- 277 -
APPENDIX C – VII
Minnesota Multiphasic Personality Inventory – 2 – MMPI-2
(Hataway & Mckinley, 1989)
INSTRUÇÕES
Este questionário contém uma série de frases. Leia cada uma delas e decida se
aplicadas a si são verdadeiras ou falsas. Anote as suas respostas na folha de resposta que
lhe foi fornecida.
Se uma das frases se aplica si é verdadeira ou quase sempre verdadeira deve
assinalar com o lápis o espaço correspondente por baixo da letra V. Do mesmo modo se
a frase que se aplica a si é falsa ou quase sempre falsa deve assinalar o espaço situado
debaixo da letra F. Veja como se faz no seguinte exemplo:
Frases
Na folha de resposta
V
F
V
F
1. Gosto de música
2. Levanto-me mal disposto
Se o conteúdo de uma frase não se aplica ao seu caso ou então é algo de que não
poderia decidir se é verdadeiro ou falso não faça nenhuma marca e deixe o espaço em
branco.
Lembre-se que deve dar a sua própria opinião sobre si. Procure ser SINCERO/A
CONSIGO MESMO/A.
Ao marcar as suas respostas na folha de resposta assegure-se que o número da
frase à qual está a responder corresponde ao número colocado ao lado do espaço que
você marca. Faça uma cruz bem visível nesse espaço. Se desejar mudar alguma resposta
risque por completo o espaço e marque o outro com uma cruz. No entanto procure não
deixar respostas em branco.
NÃO ESCREVA NADA NESTE CADERNO
AGORA ABRA O CADERNO E COMECE A RESPONDER ÀS QUESTÕES
- 278 -
1. Gosto de revistas de mecânica.
18. Sofro de náuseas e vómitos.
2. Tenho bom apetite.
19. Quando aceito um novo emprego gosto
de saber com quem é importante ser
agradável.
3. Levanto-me de manhã quase sempre
“fresco/a” e descansado/a.
20. Raramente estou indisposto/a.
4. Acho que gostaria de trabalhar como
bibliotecário/a.
21. Há alturas em que tenho desejado
muitíssimo abandonar a minha casa.
5. Acordo facilmente com o barulho.
22. Ninguém parece compreender-me.
6. O meu pai é um bom homem ou (se já
faleceu) o meu pai foi um bom homem.
23. Por vezes tenho ataques de riso ou
choro que não consigo controlar.
7. Gosto de ler artigos dos jornais sobre
crimes.
24. Por vezes estou possuído/a por espíritos
diabólicos.
8. Normalmente tenho os pés e as mãos
suficientemente quentes.
25. Gostaria de ser cantor/a.
9. Na minha vida diária existem muitas
coisas que me interessam.
26. Quando estou em dificuldades ou
problemas o melhor é calar-me.
10. Actualmente tenho tanta capacidade
para trabalhar como antes.
27. Quando alguém me faz mal sinto que se
puder devo pagar-lhe na mesma moeda,
apenas por uma questão de princípio.
11. Na maior parte do tempo parece que
tenho um nó na garganta.
28. Sinto-me mal do estômago várias vezes
por semana.
12. A minha vida sexual é satisfatória.
29. Às vezes apetece-me praguejar.
13. As pessoas deveriam tentar
compreender os seus sonhos e guiar-se por
eles ou tê-los como um aviso.
30. Frequentemente tenho pesadelos
durante a noite.
14. As histórias de detectives e de mistério
divertem-me.
31. Custa-me bastante concentrar-me numa
tarefa ou num trabalho.
15. Trabalho sob uma tensão muito grande.
32. Já passei por experiências muito
peculiares e estranhas.
16. De vez em quando penso em coisas
demasiado indecentes para poder falar
nelas.
33. Raramente me preocupo com a minha
saúde.
17. Estou certo de que a vida é dura para
mim.
34. Nunca tive problemas por causa do meu
comportamento sexual.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 279 -
35. Quanto era jovem houve ocasiões em
que roubei algumas coisas.
51. Não leio todos os dias o editorial do
jornal.
36. Quase sempre tenho tosse.
52. Não tenho levado um tipo de vida
adequado e normal.
37. Às vezes tenho vontade de partir
coisas.
53. Frequentemente parece que sinto
ardores picadas formigueiro ou dormência
em algumas partes do corpo.
38. Tive períodos de dias semanas ou
meses em que não conseguia preocupar-me
com as coisas porque não tinha ânimo para
nada.
54. A minha família não gosta do trabalho
que escolhi (ou o trabalho que penso
escolher para o meu futuro).
39. O meu sono é irregular e intranquilo.
55. Às vezes insisto tanto numa coisa que
os outros acabam por perder a paciência
comigo.
40. A maior parte do tempo parece que me
dói a cabeça toda.
56. Gostaria de ser tão feliz como os outros
parecem ser.
41. Não digo sempre a verdade.
57. Raramente sinto dores na nuca.
42. Se os outros não me quisessem mal eu
teria tido muito mais sucesso.
58. Penso que a grande maioria das pessoas
exagera as suas desgraças para conquistar a
simpatia e a ajuda dos outros.
43. O meu raciocínio está agora melhor do
que nunca.
59. Sinto um mal-estar no estômago quase
todos os dias.
44. Uma vez por semana ou mais
frequentemente sinto calor por todo o
corpo sem causa aparente.
60. Quando estou com pessoas incomodame ouvir coisas muito estranhas.
45. Tenho uma saúde física tão boa como a
maior parte dos meus amigos.
61. Sou uma pessoa importante.
46. Prefiro passar-me por despercebido
com os amigos da escola ou com pessoas
conhecidas que não vejo há muito tempo, a
não ser que falem primeiro comigo.
62. Desejo frequentemente ser mulher, (ou
se você é mulher) nunca me incomodou ser
mulher.
47. Quase nunca me dói o peito ou o
coração.
63. Os meus sentimentos não são
facilmente feridos.
48. Em diversas ocasiões gostaria de me
sentar e sonhar acordado/a do que fazer
qualquer outra coisa.
64. Gosto de ler histórias de amor.
49. Sou uma pessoa muito sociável.
65. Sinto-me triste a maior parte do tempo.
50. Tive de receber frequentemente ordens
de pessoas que sabiam menos do que eu.
66. Seria melhor se quase todas as leis
fossem abolidas.
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67. Gosto de poesia.
83. Tenho muito poucas discussões com as
pessoas da minha família.
68. Às vezes arrelio os animais.
84. Fui suspenso da escola uma ou mais
vezes por mau comportamento.
69. Acho que gostaria de trabalhar como
guarda florestal.
85. Por vezes sinto fortes desejos de fazer
algo prejudicial ou chocante.
70. Deixo-me vencer facilmente numa
discussão ou num debate.
86. Gosto de participar em reuniões ou
festas onde haja muita animação.
71. Actualmente é-me difícil não perder a
esperança de chegar a ser alguém.
87. Confrontei-me com problemas que por
terem diversas opções de solução me foi
impossível chegar a uma decisão.
72. Às vezes a minha alma abandona o
meu corpo.
88. Acredito que a mulher deve ter tanta
liberdade sexual como o homem.
73. Sem dúvida alguma não tenho
confiança em mim mesmo/a.
89. Os conflitos mais graves que tenho são
comigo mesmo/a.
74. Gostaria de ser florista.
90. Gosto do meu pai (ou se já faleceu)
gostava do meu pai.
75. Geralmente sinto que a vida merece ser
vivida.
91. Raramente ou nunca tenho espasmos ou
cãibras musculares.
76. Dá muito trabalho convencer a maioria
das pessoas da verdade.
92. Parece que não me importo muito com
o que me possa acontecer.
77. De vez em quando deixo para amanhã
o que deveria fazer hoje.
93. Por vezes fico de mau humor quando
não me sinto bem.
78. A maior parte das pessoas que me
conhecem gostam de mim.
94. Muitas vezes sinto que fiz alguma coisa
mal ou errada.
79. Não me importo que façam troça de
mim.
95. Estou quase sempre feliz.
80. Gostaria de ser enfermeiro/a.
96. Vejo à minha volta coisas animais ou
pessoas que os outros não vêem.
81. Acho que a maioria das pessoas é capaz
de mentir para obter aquilo que quer.
82. Faço muitas coisas de que logo me
arrependo. (Arrependo-me mais dos que os
outros parecem fazê-lo).
97. A minha cabeça e o meu nariz parecem
estar congestionados a maior parte do
tempo.
98. Algumas pessoas são tão autoritárias
que me apetece fazer o contrário do que me
pedem ainda que eu saiba que elas têm
razão.
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99. Alguém rogou-me uma praga.
114. Por vezes sinto-me tão atraído/a pelas
coisas pessoais dos outros (como sapatos
luvas etc.) que desejaria pegá-los ou roubálos mesmo que não precise deles.
100. Nunca fiz algo perigoso só pela
emoção de o fazer.
115. Quando vejo sangue não tenho medo
nem me sinto mal.
101. Frequentemente tenho a impressão de
ter a cabeça apertada à volta.
116. Não consigo compreender porque
tenho andado frequentemente tão irritável e
mal-humorado/a.
102. Às vezes zango-me.
117. Nunca vomitei ou cuspi sangue.
103. Gosto mais de um jogo ou uma
partida quando aposto.
118. Não me preocupa poder contrair
doenças.
104. A maioria das pessoas é honesta por
ter medo de ser descoberta.
119. Gosto de ter flores ou cultivar plantas
em casa.
105. Na escola fui chamado/a ao director
algumas vezes pelo meu mau
comportamento.
106. A minha maneira de falar é igual ao
que sempre foi (nem mais rápida nem mais
lenta nem balbuciante nem rouca).
107. Os meus modos de estar à mesa não
são tão correctos em minha casa do que
quando como fora.
108. Qualquer pessoa que seja capaz e
esteja disposta a trabalhar arduamente tem
muitas probabilidades de ter êxito.
109. Parece-me que sou tão esperto/a e
capaz como a maior parte dos que me
rodeiam.
110. A maioria das pessoas é capaz de
utilizar meios pouco honestos para não
perder um benefício ou uma vantagem.
120. Frequentemente acho que é necessário
defender o que é justo.
121. Nunca me envolvi em práticas sexuais
fora do comum.
122. Às vezes os meus pensamentos andam
mais depressa do que as minhas palavras.
123. Se pudesse entrar num cinema sem
pagar e tivesse seguro/a de que não iria ser
visto/a provavelmente o faria.
124. Pergunto-me geralmente que razão
oculta poderá ter uma pessoa quando me
faz um favor.
125. Creio que a minha vida familiar é tão
agradável como a da maioria das pessoas
que conheço.
111. Tenho muitos problemas de estômago.
126. Acredito na força da lei.
112. Gosto de teatro.
127. As críticas e as repreensões magoamme profundamente.
113. Sei quem é o responsável pela maioria
dos meus problemas.
128. Gosto de cozinhar.
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- 282 129. A minha conduta é maioritariamente
influenciada pelo comportamento dos que
me rodeiam.
145. Acho que tenho sido muitas vezes
castigado/a sem nenhum motivo.
130. Por vezes sinto-me de facto um inútil.
146. Choro facilmente.
131. Quando era criança pertencia a um
grupo de amigos que tentava manter-se
unido perante qualquer adversidade.
147. Não consigo compreender tão bem o
que leio como antes.
132. Acredito que existe outra vida depois
desta.
148. Nunca me senti tão bem na minha vida
como agora.
133. Gostaria de ser militar.
149. Por vezes sinto a parte superior da
cabeça dorida.
134. Por vezes sinto desejo de andar aos
murros com alguém.
150. Às vezes sinto vontade de fazer mal a
mim ou a alguém.
135. Frequentemente desperdiço ou não
aproveito oportunidades porque não me
decidi a tempo.
136. Quando estou a trabalhar em algo
importante, fico impaciente se as pessoas
me interrompam ou me pedem uma
opinião.
151. Aborrece-me o facto de alguém se ter
aproveitado de mim ao ponto de eu ter
reconhecido que o conseguiu.
152. Não me canso facilmente.
137. Costumava ter um diário.
153. Gosto de conhecer algumas pessoas
importantes porque isso faz-me sentir
importante.
138. Acredito que estão a planear algo
contra mim.
154. Tenho medo quando olho para baixo
de um lugar alto.
139. Num jogo ou numa partida gosto mais
de ganhar do que perder.
155. Não ficaria nervoso se um familiar
meu tivesse problemas com a lei.
140. A maior das noites adormeço sem
pensamentos ou ideias que me aborreçam.
156. Só estou feliz quando ando sem
destino ou viajo de um lado para o outro.
141. Durante os últimos anos tenho gozado
quase sempre de boa saúde.
157. Não me preocupo com o que os outros
pensam sobre mim.
142. Nunca sofri um ataque ou convulsões.
158. Sinto-me incomodado/a quando tenho
que fazer uma palhaçada numa festa mesmo
que os que outros também o façam.
143. Neste momento não estou a ganhar
nem a perder peso.
159. Nunca desmaiei.
144. Acho que me estão a perseguir.
160. Gostava da escola.
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161. Frequentemente tenho que me
esforçar para esconder a minha timidez.
178. Por vezes quando fico embaraçado/a
começo a suar, o que me incomoda imenso.
162. Alguém tem tentado envenenar-me.
179. Não tenho tido dificuldades em manter
o equilíbrio quando caminho.
163. Não tenho muito medo de cobras.
180. Alguma coisa não funciona bem na
minha cabeça.
164. Nunca ou raramente tenho tonturas.
181. Não tenho crises de “febre dos fenos”
ou de asma.
165. A minha memória parece estar boa.
182. Já tive ataques durante os quais perdi o
controlo dos meus movimentos ou da fala
mas sabia o que se estava a passar à minha
volta.
166. Estou preocupado/a com sexo.
183. Não gosto de todas as pessoas que
conheço.
167. Acho difícil iniciar uma conversa com
pessoas que acabei de conhecer.
184. É raro sonhar acordado.
168. Houve períodos durante os quais
realizei actividades que depois não me
recordava de as ter feito.
185. Gostava de não ser tão tímido/a.
169. Quando estou aborrecido/a gosto de
provocar alguma excitação.
186. Não tenho medo de lidar com o
dinheiro.
170. Tenho medo de enlouquecer.
187. Se fosse jornalista gostaria muito de
fazer reportagens sobre teatro.
171. Sou contra dar dinheiro aos mendigos.
188. Aprecio uma grande variedade de
jogos e passatempos.
172. Noto frequentemente que as minhas
mãos tremem quando tento fazer alguma
coisa.
189. Gosto de namoriscar.
173. Consigo ler durante muito tempo sem
cansar a minha vista.
190. A minha família trata-me mais como
uma criança do que como um adulto.
174. Gosto de ler e estudar coisas sobre as
quais estou a trabalhar.
191. Gostava de ser jornalista.
175. A maior parte do tempo sinto uma
fraqueza geral.
192. A minha mãe é uma boa mulher (ou se
já faleceu) a minha mãe foi uma boa
mulher.
176. É raro ter dores de cabeça.
193. Quando ando tenho muito cuidado
com os buracos do passeio.
177. As minhas mãos não se tornaram
desajeitadas nem perderam a habilidade.
194. Nunca tive nenhuma erupção na pele
que me tivesse preocupado.
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195. Na minha família há pouca união e
afecto comparado com outras famílias.
196. Frequentemente dou comigo
preocupado/a com alguma coisa.
211. Fui inspirado num estilo de vida
baseado no dever o qual tenho seguido
cuidadosamente.
212. Por vezes impedi alguém de fazer
alguma coisa não porque fosse importante
mas por questão de princípios.
197. Acho que gostaria da profissão de
encarregado de obras.
213. Fico facilmente furioso mas passa-me
depressa.
198. Oiço frequentemente vozes que não
sei de onde vêm.
214. Tenho sido bastante livre e
independente da disciplina familiar.
199. Gosto de ciência.
215. Preocupo-me muito com as coisas.
200. Não me custa pedir ajuda aos meus
amigos mesmo que não possa devolverlhes o favor.
216. Alguém tentou roubar-me.
201. Gosto muito de caçar.
217. Quase todos os meus familiares
simpatizam comigo.
202. Os meus pais opuseram-se muitas
vezes ao tipo de pessoas com quem me
dava.
218. Tenho períodos de tanta agitação que
não consigo estar muito tempo sentado/a
numa cadeira.
203. Às vezes sou um pouco bisbilhoteiro.
219. Sofri desgostos amorosos.
204. Aparentemente oiço tão bem como a
maioria das pessoas.
220. Nunca me preocupo com a minha
aparência física.
205. Alguns dos meus familiares têm
hábitos que me aborrecem e incomodam
muitíssimo.
206. Às vezes sinto que sou capaz de tomar
decisões com uma facilidade
extraordinária.
221. Sonho frequentemente com coisas que
é melhor guardá-lo para mim.
222. Deveriam ensinar-se às crianças todos
os aspectos principais da vida sexual.
207. Gostaria de pertencer a vários clubes
ou associações.
223. Acho que não sou mais nervoso/a do
que a maioria das pessoas.
208. Raramente sinto palpitações no
coração ou falta de ar.
224. Tenho poucas ou nenhumas dores.
209. Gosto de falar sobre sexo.
225. A minha maneira de fazer as coisas
tende a ser mal interpretada pelos outros.
210. Gosto de visitar lugares onde nunca
estive.
226. Algumas vezes sem nenhuma razão
mesmo quando as coisas correm mal sintome extremamente feliz como se “andasse
nas nuvens”.
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- 285 227. Não censuro as pessoas que procuram
tirar partido de tudo o que podem, neste
mundo.
228. Existem pessoas que tentam roubar os
meus pensamentos e as minhas ideias.
229. Tive momentos de tanta confusão que
interrompi as minhas actividades e não
sabia o que se passava à minha volta.
230. Consigo ser amigável com pessoas
que fazem coisas que eu considero
incorrectas.
243. Quando estou com um grupo de
pessoas tenho dificuldade em pensar em
temas adequados para falar.
244. Quando me sinto abatido/a alguma
coisa emocionante me tira quase sempre
desse estado.
245. Quando saio de casa não me preocupo
se a porta ou as janelas ficaram bem
fechadas.
246. Acredito que os meus pecados são
imperdoáveis.
231. Gosto de estar em grupos em que as
pessoas brincam umas com as outras.
247. Tenho uma ou mais partes da minha
pele dormentes.
232. Algumas vezes voto nas eleições em
pessoas que não conheço muito bem.
248. Não censuro uma pessoa que se
aproveita de outra se essa outra deixar.
233. Tenho dificuldade em começar a fazer
coisas.
249. A minha vista está tão boa agora como
sempre esteve.
234. Acredito que sou uma pessoa
condenado/a.
235. Quando andava na escola era lento a
aprender.
250. Às vezes diverte-me tanto uma
habilidade de um patife que chego a desejar
que não seja apanhado.
251. Frequentemente tenho a sensação de
que desconhecidos olham para mim de uma
forma crítica.
236. Se fosse artista gostaria de desenhar
flores.
252. Tudo tem o mesmo sabor.
237. Não me preocupa o facto de não ter
uma melhor aparência física.
253. Bebo uma quantidade excessiva de
água todos os dias.
238. Transpiro muito facilmente mesmo
nos dias frios.
254. A maior parte das pessoas faz amigos
porque é provável que lhes venham a ser
úteis.
239. Sou uma pessoa plenamente segura de
mim mesma.
255. É raro sentir zumbidos ou assobios nos
ouvidos.
240. Algumas vezes não consegui evitar
roubar algo ou levar alguma coisa de uma
loja.
256. Por vezes sinto ódio de familiares de
quem normalmente gosto.
241. É mais seguro não confiar em
ninguém.
257. Se fosse jornalista gostava muito de
fazer reportagens sobre desporto.
242. Fico muito agitado/a uma vez por
semana ou até com mais frequência.
258. Consigo dormir durante o dia mas não
à noite.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 286 -
259. Tenho a certeza de que as pessoas
falam de mim.
275. Na escola custava-me muito falar
perante a turma.
260. De vez em quando as piadas
ordinárias divertem-me.
276. Gosto da minha mãe (ou se já faleceu)
gostei da minha mãe.
261. Tenho muito poucos medos
comparado com os meus amigos.
277. Mesmo quando estou com pessoas
sinto-me sozinho/a a maior parte do tempo.
262. Não sentiria qualquer vergonha se
estivesse num grupo e me pedissem para
começar um debate ou dar a minha opinião
acerca de algo que conheço bem.
263. Sinto-me sempre desgostoso/a com a
justiça quando um criminoso sai em
liberdade graças aos argumentos de um
advogado astuto.
278. Tenho toda a compreensão que deveria
receber.
279. Recuso-me a participar em alguns
jogos porque não sou bom neles.
264. Tenho abusado das bebidas alcoólicas.
280. Parece-me que faço amigos tão
facilmente como os outros.
265. Geralmente não falo às pessoas a não
ser que elas me falem primeiro.
281. Não gosto de ter gente à minha volta.
266. Nunca tive problemas com a lei.
282. Disseram-me que ando enquanto estou
a dormir.
267. Tenho alturas em que me sinto mais
animado/a sem nenhuma razão especial.
283. Quem provoca a tentação deixando
uma coisa valiosa sem a proteger, é tão
culpado do roubo como o próprio ladrão.
268. Gostaria de não ser incomodado/a por
pensamentos de ordem sexual.
284. Penso que quase toda a gente mentiria,
para evitar problemas.
269. Se várias pessoas se encontram
metidas num sarilho, o melhor que têm a
fazer é concordarem numa história e
agarrarem-se a ela.
285. Sou mais sensível que a maioria das
pessoas.
270. Não me incomoda particularmente ver
os animais a sofrer.
286. No fundo, a maior parte das pessoas
não gosta de se incomodar para ajudar os
outros.
271. Acho que sinto as coisas mais
intensamente do que a maioria das pessoas.
287. Muitos dos meus sonhos estão
relacionados com sexo.
272. Em nenhum período da minha vida
gostei de brincar com bonecas.
288. Os meus pais e a minha família
encontram em mim mais defeitos do que
deviam.
273. Com frequência a vida é-me difícil.
289. Facilmente me sinto envergonhado/a.
274. Sou tão sensível em relação a alguns
temas que nem sequer posso falar neles.
290. Preocupo-me com o dinheiro e os
negócios.
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291. Nunca estive apaixonado/a por
ninguém.
307. Às vezes, oiço tão bem que me chega a
incomodar.
292. Algumas pessoas da minha família
fizeram coisas que me assustaram.
308. Esqueço logo aquilo que me dizem.
293. Quase nunca sonho.
309. Normalmente, tenho que pensar
primeiro antes de agir, mesmo em assuntos
pouco importantes.
294. Aparecem-me com frequência
manchas vermelhas no pescoço.
310. Frequentemente atravesso a rua para
evitar encontrar-me com alguma pessoa.
295. Nunca fiquei paralisado nem tive
qualquer debilidade invulgar de natureza
muscular.
296. Algumas vezes fico sem voz ou a
minha voz altera-se mesmo não estando
constipado/a.
297. Frequentemente a minha mãe ou o
meu pai obrigaram-me a obedecer mesmo
quando eu pensava que não tinham razão.
311. Frequentemente sinto as coisas como
se não fossem reais.
312. A única parte interessante dos jornais
são as caricaturas da secção cómica.
313. Tenho o costume de contar coisas sem
importância, como as letras de um anúncio
de rua ou outras semelhantes.
298. Às vezes sinto cheiros estranhos.
314. Não tenho inimigos que desejem
realmente fazer-me mal.
299. Não consigo concentrar-me numa só
coisa.
315. Tenho tendência a acautelar-me com
as pessoas que são mais amigáveis comigo
do que esperava.
300. Tenho motivos para sentir ciúmes de
um ou mais membros da minha família.
316. Tenho pensamentos estranhos e raros.
301. A maior parte do tempo sinto-me
ansioso com alguma coisa ou com alguém.
317. Fico nervoso/a e inquieto/a, quando
tenho que fazer uma pequena viagem.
302. Facilmente perco a paciência com as
pessoas.
318. Normalmente, espero ter êxito nas
coisas que faço.
303. Na maior parte do tempo desejaria
estar morto.
319. Oiço coisas estranhas quando estou
sozinho/a.
304. Algumas vezes, sinto-me tão
inquieto/a que me custa adormecer à noite.
320. Tive medo de coisas ou pessoas que eu
sabia que não me podiam fazer mal.
305. Sem dúvida, tive que me preocupar
com mais coisas do que as que me diziam
respeito.
321. Não tenho receio de entrar sozinho/a
numa sala onde outras pessoas já estão
reunidas a conversar.
306. Ninguém se preocupa o suficiente
com o que acontece comigo.
322. Tenho medo de utilizar facas ou
objectos muito afiados e pontiagudos.
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- 288 -
323. Por vezes, gosto de magoar as pessoas
que amo.
339. Por vezes tenho sentido que as
dificuldades me sobrecarregam de tal modo
que não consigo superá-las.
324. Facilmente consigo que as pessoas
tenham medo de mim e, às vezes faço-o
por divertimento.
340. Gosto muito de ir dançar.
325. Para mim é mais difícil concentrar-me
do que parece ser para as outras pessoas.
341. Há alturas em que a minha mente
parece funcionar mais lentamente que o
costume.
326. Houve várias ocasiões em que desisti
de fazer algo, porque duvidei das minhas
capacidades.
327. Quando me vêm à minha cabeça
palavrões ou palavras terríveis não consigo
libertar-me deles/as.
328. Por vezes sinto que um pensamento
sem importância anda às voltas na minha
cabeça atormentando-me durante dias.
329. Quase todos os dias, acontece alguma
coisa que me assusta.
330. Às vezes estou cheio/a de energia.
331. Tenho tendência a levar as coisas
demasiado a sério.
342. Quando viajo falo frequentemente com
pessoas que não conheço.
343. Gosto de crianças.
344. Gosto de apostar quando se trata de
pouco dinheiro.
345. Se me dessem oportunidade poderia
fazer coisas que beneficiariam muito a
humanidade.
346. Tenho encontrado frequentemente
pessoas supostamente mais experientes,
mas que não se mostraram melhores do que
eu.
347. Sinto-me um/a fracassado/a quando
me falam do sucesso de alguém que
conheço bem.
332. Por vezes tive ocasiões em que senti
prazer em ser magoado/a por uma pessoa
de quem gostei muito.
348. Penso com frequência: “Gostava de
voltar a ser criança”.
333. As pessoas insultam-me e dizem
coisas ordinárias a meu respeito.
349. Nunca sou tão feliz, como quando
estou sozinho/a.
334. Sinto-me aflito/a em lugares fechados.
350. Se me dessem a oportunidade, poderia
ser um bom/boa líder.
335. Não sou particularmente tímido/a.
351. Sinto-me incomodado/a quando oiço
anedotas ordinárias.
336. Alguém tem o controlo sobre a minha
mente.
352. Normalmente as pessoas exigem mais
respeito para os seus próprios direitos do
que aqueles que estão dispostas a ceder aos
outros.
337. Em reuniões sociais ou em festas, é
mais provável que me sente sozinho/a ou
com uma pessoa, em vez de me reunir com
um grupo.
353. Gosto de reuniões sociais pelo simples
facto de estar com pessoas.
338. As pessoas desiludem-me com muita
frequência.
354. Tento recordar histórias interessantes
para poder contá-las aos outros.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 289 355. Uma ou mais vezes, na minha vida
senti que por hipnotismo alguém me
obrigava a fazer algo.
356. Custa-me bastante interromper, ainda
que seja por pouco tempo, uma tarefa que
já tinha iniciado.
357. Normalmente não participo nos
mexericos e boatos do grupo a que
pertenço.
358. Encontro com frequência pessoas com
inveja das minhas boas ideias
simplesmente porque não lhes ocorreram
primeiro.
371. Frequentemente desejei pertencer ao
sexo oposto.
372. Não me zango facilmente.
373. No passado fiz coisas erradas que
nunca contei a ninguém.
374. A maioria das pessoas utilizaria meios
pouco honestos para subir na vida.
359. Gosto da animação de uma multidão.
375. Sinto-me nervoso/a quando as pessoas
me fazem perguntas pessoais.
360. Não me importo de encontrar pessoas
desconhecidas.
376. Sinto que não posso planificar o meu
próprio futuro.
361. Alguém tem tentado influenciar a
minha mente.
377. Não estou satisfeito/a com a minha
maneira de ser.
362. Lembro-me de ter fingido estar doente
para evitar alguma coisa.
378. Zango-me quando os meus amigos ou
familiares me dizem como devo viver a
minha vida.
363. As minhas preocupações parecem
desaparecer quando estou num grupo de
amigos.
379. Bateram-me muito quando era criança.
364. Quando as coisas correm mal
facilmente me dou por vencido/a.
380. Sinto-me incomodado/a quando as
pessoas me elogiam.
365. Gosto que as pessoas conheçam o meu
ponto de vista sobre as coisas.
381. Não gosto de ouvir outras pessoas a
dar as suas opiniões sobre a vida.
366. Tive alturas em que me sentia tão
animado/a que parecia que durante dias não
precisava dormir.
382. Com frequência discordo
profundamente das pessoas que me são
próximas.
383. Quando as coisas estão realmente mal,
sei que posso contar com a ajuda da minha
família.
367. Sempre que possível evito estar no
meio de muita gente.
368. Evito enfrentar uma crise ou
dificuldades.
384. Quando era pequeno/a gostava de
brincar às “casinhas”.
369. Tenho tendência a deixar de fazer
coisas que desejo quando os outros pensam
que não vale a pena fazê-lo.
385. Não tenho medo do fogo.
370. Gosto de festas e reuniões sociais.
386. Houve ocasiões em que me afastei de
pessoas porque tive medo de fazer ou de
dizer alguma coisa de que logo me viesse a
arrepender.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 290 -
387. Só quando bebo é que consigo
expressar os meus verdadeiros sentimentos.
403. Frequentemente, as pessoas
interpretam mal as minhas intenções
quando procuro corrigi-las ou ajudá-las.
388. Muito raramente tenho momentos de
desânimo.
404. Não tenho dificuldades em engolir.
389. Dizem-me frequentemente que tenho
mau feitio.
405. Normalmente sou uma pessoa calma e
não me altero facilmente.
390. Queria poder esquecer-me de coisas
que disse e que talvez possam ter ferido os
sentimentos de outras pessoas.
406. Seguramente gostaria de vencer uma
pessoa manhosa recorrendo às mesmas
armas que ela utiliza.
391. Sinto-me incapaz de contar a alguém
tudo a meu respeito.
407. Mereço ser rigorosamente castigado/a
pelos meus pecados.
392. Os relâmpagos são um dos meus
medos.
408. As desilusões afectam-me tanto que
não posso deixar de pensar nelas.
393. Gosto de deixar os outros curiosos
com o que vou fazer a seguir.
394. Encontro frequentemente tantas
dificuldades nos meus planos que tenho
que os abandonar.
409. Incomoda-me que me observem
quando estou a trabalhar, mesmo que saiba
que o posso fazer bem.
410. Frequentemente chateia-me tanto que
se ponham à minha frente numa fila, que
não consigo evitar de chamar à atenção.
395. Tenho medo de estar sozinho/a no
escuro.
411. Às vezes penso que não valho nada.
396. Houve alturas em que me senti muito
mal por não ter sido compreendido/a
quando tentava evitar que alguém
cometesse um erro.
412. Quando era miúdo/a frequentemente
não ia à escola mesmo quando devia ir.
397. Tenho pavor dos temporais com vento
muito forte.
413. Um ou mais dos meus familiares são
muito nervosos.
398. Peço frequentemente conselhos aos
outros.
414. Por vezes tive de ser duro com pessoas
mal-educadas ou desagradáveis.
399. O futuro é demasiado incerto para que
uma pessoa faça planos importantes.
415. Preocupo-me bastante com possíveis
desgraças.
400. Com frequência mesmo quando tudo
me está a correr bem, sinto que nada me
importa.
416. Tenho opiniões políticas bem
definidas.
401. Não tenho medo da água.
417. Gostaria de ser piloto de automóveis
de competição.
402. Com frequência tenho que “consultar
a almofada” antes de tomar uma decisão.
418. É correcto contornar os limites da lei
desde que na realidade não a violemos.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 291 419. Desagradam-me tanto algumas pessoas que
fico interiormente satisfeito/a quando sofrem as
consequências do que fizeram.
420. Ter de esperar deixa-me nervoso/a.
421. Tenho tendência a deixar de fazer alguma
coisa que desejo quando os outros pensam que
essa não é a melhor maneira de o fazer.
435. Frequentemente tenho medo do escuro.
436. Quando um homem está com uma
mulher pensa, geralmente, em coisas
relacionadas com sexo.
437. Geralmente “sou muito directo “a falar
com as pessoas que tento corrigir ou
melhorar.
422. Quando era mais jovem adorava tudo o que
era emocionante.
438. Aterroriza-me a ideia de um terramoto.
423. Frequentemente esforço-me por vencer
alguém que me enfrenta.
439. Rapidamente me convencem totalmente
de uma boa ideia.
424. Incomoda-me que as pessoas olhem para
mim na rua, nos transportes, nas lojas, etc.
440. Geralmente faço as coisas por mim
mesmo/a, em vez de procurar alguém que me
diga como fazê-las.
425. O homem que mais cuidou de mim quando
eu era criança (o meu pai, o meu padrasto, etc.)
foi muito rígido comigo.
441. Tenho medo de estar num lugar pequeno
ou fechado.
426. Gosto de jogar “à macaca” (apanhar uma
pedra no chão ao pé coxinho) e saltar à corda.
427. Nunca tive visões.
442. Tenho que admitir que por vezes me
preocupo demasiado com algo sem
importância.
443. Não procuro disfarçar ou esconder a
pena ou a fraca opinião que tenho de uma
pessoa, ao ponto de ela desconhecer o que eu
sinto.
428. Mudei várias vezes a minha forma de sentir
em relação ao meu trabalho.
444. Sou uma pessoa muito nervosa.
429. A não ser por receita médica, nunca tomo
drogas ou comprimidos para dormir.
445. Trabalhei, frequentemente, sob ordens de
pessoas que pareciam organizar as coisas de
maneira a terem o reconhecimento de um bom
trabalho, mas que em contrapartida eram
capazes de atribuir os seus erros aos
empregados.
430. Frequentemente lamento ter tão mau feitio
ou ser tão resmungão/ona.
446. Por vezes é-me difícil defender os meus
direitos por ser tão calado/a.
431. Na escola as minhas notas de
comportamento foram geralmente más.
447. A sujidade apavora-me ou enoja-me.
432. O fogo fascina-me.
448. Vivo uma vida de sonhos, da qual não
revelo nada a ninguém.
433. Quando estou numa situação difícil, digo
apenas a parte da verdade que provavelmente
não me vai prejudicar.
434. Se tiver em dificuldades com amigos que
são tão culpados como eu, prefiro ficar com a
culpa toda em vez de os acusar.
449. Alguns dos meus familiares “fervem em
pouca água”.
450. Não consigo fazer nada bem feito.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 292 -
451.Frequentemente sinto-me culpado/a por
fingir sofrer mais do que aquilo que
realmente sinto.
467. Gosto de ler sobre temas científicos.
452. Como regra defendo fortemente as
minhas opiniões.
468. Tenho medo de estar sozinho/a em
lugares amplos e abertos.
453. Não tenho medo de aranhas.
469. Às vezes sinto que estou à beira de um
“ataque de nervos”.
454. Não tenho esperança no meu futuro.
470. Um grande número de pessoas é culpado
de um mau comportamento sexual.
455. Os meus familiares mais próximos dãose muito bem.
471. Frequentemente sinto medo a meio da
noite.
456. Gosto de vestir roupa cara.
472. Aborrece-me muito esquecer onde ponho
as coisas.
457. As pessoas podem fazer-me mudar de
opinião facilmente mesmo nos assuntos em
que penso ter uma ideia bem definida.
473. A pessoa por quem senti mais afecto e
admiração quando era pequeno/a, foi uma
mulher (mãe, irmã, tia ou outra mulher).
458. Alguns animais deixam-me nervoso/a.
474. Gosto mais de histórias de aventuras do
que românticas.
459. Consigo suportar a dor, tanto como as
outras pessoas.
475. Frequentemente sinto-me confuso/a e
esqueço-me do que quero dizer.
460. Por diversas vezes, fui o/a último/a a
dar-me por vencido/a ao tentar fazer alguma
coisa.
476. Sou muito desajeitado/a e pouco
desembaraçado/a.
461. Irrito-me quando os outros me
apressam.
477. Gosto, realmente, de jogar desportos
violentos (como o rugby e o futebol).
462. Não tenho medo de ratos.
478. Odeio toda a minha família.
463. Várias vezes por semana sinto que vai
acontecer algo terrível.
479. Algumas pessoas pensam que é difícil
chegar a conhecer-me.
464. Sinto-me cansado/a a maior parte do
tempo.
480. Passo sozinho/a a maior parte do meu
tempo livre.
465. Gosto de consertar as fechaduras das
portas.
481. Quando alguém faz alguma coisa que me
irrita, faço com que o saiba.
466. Algumas vezes tenho a certeza de que os
outros podem saber o que estou a pensar.
482. Frequentemente custa-me decidir o que
devo fazer.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 293 -
483. As pessoas não me consideram atraente.
484. As pessoas não se mostram muito
amáveis comigo.
485. Sinto com frequência que não sou tão
bom/boa como as outras pessoas.
499. Detesto ir ao médico mesmo quando
estou doente.
500. Mesmo não estando contente com a
minha vida já não posso fazer nada para a
mudar.
501. Frequentemente é mais proveitoso falar
dos problemas e preocupações com alguém
do que tomar calmantes e medicamentos.
486. Sou muito teimoso/a (decidido/a
insistente).
502. Tenho alguns hábitos que realmente me
fazem mal.
487. Gostei de consumir drogas.
503. Quando é preciso resolver problemas
habitualmente deixo que os outros os
resolvam.
488. A doença mental é um sinal de
debilidade.
504. Reconheço que tenho alguns defeitos que
não serei capaz de mudar.
489. Tenho problemas com as drogas e com o
álcool.
505. Estou tão farto/a das coisas que tenho
que fazer diariamente que tenho vontade de
abandonar tudo.
490. Os fantasmas e os espíritos podem
influenciar as pessoas para o bem e para o
mal.
506. Recentemente pensei em matar-me.
491. Sinto-me incapaz quando tenho que
tomar uma decisão importante.
507. Frequentemente irrito-me muito quando
as pessoas interrompem o meu trabalho.
492. Procuro sempre ser amável mesmo
quando os outros se mostram aborrecidos e
críticos.
508. Sinto com frequência que posso ler a
mente dos outros.
493. Quando tenho algum problema aliviame poder falar com alguém.
509. Fico nervoso/a ao ter que tomar decisões
importantes.
494. Os objectivos mais importantes da
minha vida estão ao meu alcance.
510. Dizem que como demasiado rápido.
495. Acho que as pessoas deveriam guardar
para si os seus problemas pessoais.
511. Uma vez por semana ou com mais
frequência costumo embebedar-me ou drogarme.
496. Nos últimos dias não tenho sentido
muita pressão ou stresse.
512. Sofri uma perda importante na minha
vida que não vou poder ultrapassar.
497. Aborrece-me muito pensar em fazer
mudanças na minha vida.
513. Às vezes aborreço-me e altero-me tanto
que não sei o que se passa comigo.
498. Os meus maiores problemas devem-se
ao comportamento de alguém que está
próximo de mim.
514. Quando alguém me pede para fazer
alguma coisa custa-me dizer que não.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 294 -
515. Nunca me sinto tão feliz como quando
estou sozinho/a.
531. Trabalho muitas horas mesmo que o meu
trabalho não o exija.
516. A minha vida está vazia e não tem
sentido.
532. Habitualmente sinto-me melhor depois
de chorar bastante.
517. Tenho dificuldade em manter um
trabalho.
533. Esqueço-me onde deixo as coisas.
518. Cometi bastantes erros graves na minha
vida.
534. Se pudesse começar a minha vida de
novo não a mudaria muito.
519. Chateio-me comigo mesmo/a quando
cedo perante os outros.
535. Irrito-me muito quando as pessoas das
quais dependo para trabalhar não fazem o seu
trabalho a tempo.
520. Ultimamente tenho pensado muito em
suicidar-me.
536. Se me zango tenho a certeza que me vai
doer a cabeça.
521. Gosto de tomar decisões e de organizar
o trabalho dos outros.
537. Gosto de negociar em situações difíceis.
522. Mesmo que me falte a família sei que
haverá sempre alguém que cuide de mim.
538. A maioria dos maridos é infiel às suas
esposas de vez em quando.
523. Detesto ficar na fila para os cinemas,
restaurantes ou espectáculos desportivos.
539. Ultimamente perdi o interesse em
resolver os meus próprios problemas.
524. Ninguém sabe, mas tentei suicidar-me.
540. Sob o efeito de álcool enfureci-me e
destruí móveis ou loiça.
525. Está tudo a acontecer muito rápido à
minha volta.
541. Trabalho melhor quando tenho um prazo
fixo para cumprir.
526. Sei que sou um peso para os outros.
542. Zanguei-me tanto com uma pessoa que
estive perto de explodir.
527. Depois de um mau dia, geralmente
preciso beber “uns copos” para me relaxar.
543. Por vezes tenho pensamentos terríveis
sobre a minha família.
528. Muitos dos problemas que tenho tido
devem-se ao azar.
544. As pessoas dizem-me que tenho
problemas com o álcool, mas eu não
concordo.
529. Às vezes parece que não consigo deixar
de falar.
545. Tenho sempre muito pouco tempo para
fazer as coisas.
530. Em algumas ocasiões corto-me ou firome de propósito, sem saber porquê.
546. Ultimamente os meus pensamentos
centram-se, cada vez mais, na morte e na vida
do além.
NÃO PARE CONTINUE NA PÁGINA SEGUINTE
- 295 -
547. Com frequência, guardo e conservo
coisas que provavelmente nunca usarei.
557. O homem deveria ser o chefe da família.
548. Algumas vezes zanguei-me tanto com
uma pessoa que cheguei a magoá-la
fisicamente.
558. O único lugar onde me sinto relaxado/a é
na minha própria casa.
549. Em tudo o que tenho feito ultimamente
sinto que estou a ser testado/a.
559. As pessoas com quem trabalho não
compreendem os meus problemas.
550. Actualmente relaciono-me pouco com
os meus familiares.
560. Estou satisfeito/a com o montante de
dinheiro que ganho.
551. Em certas ocasiões parece que oiço os
meus próprios pensamentos em voz alta.
561. Normalmente tenho energia suficiente
para realizar o meu trabalho.
552. Quando estou triste, visitar os meus
amigos consegue tirar-me desse estado.
562. Custa-me aceitar elogios.
553. Muitas das coisas que estão a acontecerme agora, parece que já me aconteceram
antes.
563. Na maioria dos casamentos um ou
ambos os conjugues são infelizes.
554. Quando a minha vida se complica tenho
vontade de deixar tudo.
564. Quase nunca perco o controlo de mim
mesmo/a.
555. Não consigo entrar sozinho/a num
quarto escuro mesmo na minha própria casa.
556. Preocupa-me bastante o dinheiro.
565. Ultimamente tenho que fazer um grande
esforço para me lembrar do que as pessoas me
disseram.
566. Quando estou triste e abatido/a,
geralmente é o meu trabalho que sai
prejudicado.
567. A maioria dos casais que estão casados
não demonstra muito afecto um pelo outro.
FIM DO QUESTIONÁRIO.
SE TERMINOU ANTES
DO TEMPO PROPOSTO
VERIFIQUE SE RESPONDEU
A TODAS AS QUESTÕES
- 296 -
APPENDIX D
- 297 -
Table 1
Descriptive statistics of the socio-demographic variables according to the Moment
Moment 1
Moment 2
N
%
N
%
M-F
6
27.3
6
27.3
F-M
16
72.7
16
72.7
North
4
18.2
4
18.2
Center
3
13.6
3
13.6
Lisbon and Vale do Tejo
13
59.1
13
59.1
Alentejo
2
9.1
2
9.1
University Degree
6
27.3
8
36.4
High School Degree/Technical High Degree
12
54.5
10
45.5
High School Degree/Technical Low Degree
2
9.1
4
18.2
Elementary School
2
9.1
0
.0
Level 1
5
22.7
8
36.4
Level 2
4
18.2
6
27.3
Level 3
1
4.5
2
9.1
Level 4
5
22.7
5
22.7
Student
2
9.1
0
.0
Unemployed
5
22.7
1
4.5
Active
15
68.2
21
95.5
Unemployed
5
22.7
1
4.5
Student
2
9.1
0
.0
Drugs
1
4.5
0
0.0
Tobacco
8
36.4
8
36.4
Absence
13
59.1
14
63.6
Gender
Region
Academic Qualifications
Level (GRAFFAR)*
Professional Situation
Toxic Habits
(Tablet continues)
- 298 -
Table 1 (Cont)
Moment 1
Moment 2
N
%
N
%
Single
19
86.4
16
72.7
Married
1
4.5
3
13.6
Separated / Divorced
2
9.1
3
13.6
No
11
50.0
9
40.9
Yes
11
50.0
13
59.1
Less than a 1 year
3
13.6
1
4.5
Between 1 - 3 years
2
9.1
3
13.6
Longer than 3 years
6
27.3
9
40.9
N.A.
11
50.0
9
40.9
No
19
86.4
15
68.2
Yes
3
13.6
7
31.8
One
1
4.5
4
18.2
Two
2
9.1
3
13.6
N.A.
19
86.4
15
68.2
Biological Child(ren)
3
13.6
3
13.6
Partner (s) Child (ren)
0
.0
3
13.6
Child(ren) Adopted
0
.0
1
4.5
N.A.
19
86.4
15
68.2
Oldest
5
22.7
5
22.7
Youngest
9
40.9
9
40.9
Middle
3
13.6
3
13.6
Only child
3
13.6
3
13.6
Twins
2
9.1
2
9.1
Civil Status
Stable Relationship
Stable Relationship – Specified
Children
Children – Specified
Children – Specified
Siblings – Phratry Position
- 299 -
*Graffar Professional Level
Level 1 – Bank top executives, technical business directors, university degree holders,
engineers, professionals with a university or special college degree, and top military
officers.
Level 2 – Administrative or business managers of important companies, bank vicedirectors, experts, technicians, and businessmen.
Level 3 – Technical Assistants, drawers, cashiers, foremen, first officials, tenders,
overseer, and master-builders.
Level 4 – Elementary School Completed, chauffeurs, policemen, cook, among others
(specialized workers).
Level 5 – Newsvendor, bellboys, kitchen assistants, cleaning-women, among others
(handymen or not specialized workers).
- 300 -
Table 2
Descriptive statistics of the interval/ratio variables by socio-demographic data at
Moment 1
N
Minimum
Maximum
M
SD
Age
22
19
56
27.09
10.438
Number of siblings
22
0
7
2.05
1.812
Table 3
Descriptive statistics of the interval/ratio variables by socio-demographic data at
Moment 2
N
Minimum
Maximum
M
SD
Age
22
22
62
33.5
10.004
Number of siblings
22
0
7
2.05
1.812
- 301 -
Table 4
Descriptive statistics of the clinical variables according to the Moment
Moment 1
Moment 2
N
%
N
%
No
0
.0
-
-
Yes
22
100.0
-
-
Clinical Evaluation
22
100.0
0
.0
Law Suit and Legal Recognition Process
0
.0
8
36.4
Complete
0
.0
14
63.6
No
0
.0
-
-
Yes
22
100.0
-
-
With Co- morbidities
0
.0
-
-
Without Co-morbidities
22
100.0
-
-
2001
7
31.8
-
-
2002
4
18.2
-
-
2003
2
9.1
-
-
2004
3
13.6
-
-
2005
1
4.5
-
-
2006
5
22.7
-
-
2008
-
-
6
27.3
2009
-
-
5
22.7
2010
-
-
3
13.6
RL 2010
-
-
8
36.4
No
9
40.9
8
36.4
Yes
13
59.1
14
63.6
Karyotype according to the Biological Sex
Stage of the Sexual Reassignment Process (SRP)
GID Diagnosis
GID Differential Diagnosis
SRP Starting year
SRP Terminus year
Psychiatric Care
(Table continues)
- 302 -
Table 4 (Cont)
Moment 1
Moment 2
N
%
N
%
Depressive D.
2
9.1
2
9.1
Anxiety D.
2
9.1
3
13.6
Depressive and Anxiety D.
1
4.5
1
4.5
Depressive, Anxiety and Personality D.
8
36.4
8
36.4
N.A.
9
40.9
8
36.4
Complete
0
.0
9
40.9
Maintained
13
59.1
4
18.2
Discontinued
0
.0
1
4.5
N.A.
9
40.9
8
36.4
No
0
.0
14
63.6
Yes
22
100.0
8
36.4
Maintained (different periodicity)
22
100.0
16
72.7
Discontinued
0
.0
6
27.3
N.A.
0
.0
0
.0
No
10
45.5
18
81.8
Yes
12
54.5
4
18.2
Anxiolytics and/or Antidepressants
12
54.5
4
18.2
Antipsychotics
0
.0
0
.0
N.A.
10
45.5
18
81.8
Psychiatric Care – Specified
Present Psychiatric Care
Co-Morbidities – Psychotherapy Intervention
Psychotherapy Intervention
Psychotropic
Psychotropic – Specified
Table 5
Descriptive statistics of the interval/ratio variables of clinical data (M2)
SRP Duration (years)
N
Minimum
Maximum
M
SD
14
3
8
6.64
1.393
- 303 -
Table 6
Differences in the dimensions of Symptom-Check-List-90-Revised (SCL-90) according to the Moment
Moment 1
N
Minimum
Maximum
Moment 2
TG
F-M
M-F
t
M
SD
N
Minimum
Maximum
M
SD
t
t
Primary Dimensions
Somatization
22
.08
2.70
.693
.676
22
.00
2.00
.441
.410
-
-
Obsession-Compulsion
22
.00
3.30
.964
.796
22
.00
1.80
.705
.480
-
-
-
Interpersonal Sensivity
22
.10
3.20
.993
.909
22
.00
1.22
.471
.336
2.76*
-
-
Depressivity
22
.00
3.30
1.003
.915
22
.00
1.15
.479
.373
2.79*
-
Anxiety
22
.00
2.80
.836
.777
22
.00
.90
.300
.281
3.95***
Hostility
22
.00
3.70
.594
.805
22
.00
.83
.256
.260
2.18*
-
Phobic Anxiety
22
.00
2.00
.512
.616
22
.00
1.85
.180
.400
2.29*
-
2.93*
Paranoid Ideation
22
.00
2.83
1.030
.868
22
.00
2.33
.551
.566
2.35*
-
2.61*
Psychoticism
22
.00
2.70
.696
.731
22
.00
1.00
.273
.291
3.27**
-
3.45*
Appetite -
22
0
4
1.36
1.329
22
0
2
.45
.739
3.36**
2.16*
4.00**
Sleep P.M.
22
0
4
1.95
1.327
22
0
3
.68
.894
4.20***
2.84*
5.00**
Death Thoughts
22
0
3
1.41
1.054
22
0
1
.18
.395
5.64***
3.65**
11.0***
Appetite +
22
0
2
.14
.468
22
0
4
.68
1.041
-2.42*
-
-
Sleep A.M.
22
0
4
.32
.894
22
0
4
1.18
1.368
-2.99**
-3.30**
-
Restless Sleep
22
0
4
1.64
1.217
22
0
2
.50
.740
4.42***
3.17**
4.00**
Feelings of Guilt
22
0
4
.91
1,151
22
0
2
.55
.858
-
-
-
22
.03
2.90
.858
.724
22
.01
1.16
.429
.320
3.05**
-
2.73*
2.87*
2.83*
3.43*
-
Additional Items
General Index of Symptoms
Note. *** p ≤ .001; ** p ≤ .01.
2.99*
- 304 -
Table 7
Descriptive Analysis of the thresholds “normality” and “pathologic” in the
dimensions of Symptom-Check_list-90-Revised (SCL-90) according to the Moment
Moment 1
Moment 2
N
%
N
%
“Normality”
“Pathologic”
20
2
90.9
9.1
21
1
95.5
4.5
“Normality”
“Pathologic”
18
4
81.8
18.2
21
1
95.5
4.5
“Normality”
“Pathologic”
17
5
77.3
22.7
22
0
100.0
.0
“Normality”
“Pathologic”
15
7
68.2
31.8
22
0
100.0
.0
“Normality”
“Pathologic”
19
3
86.4
13.6
22
0
100.0
.0
“Normality”
“Pathologic”
21
1
95.5
4.5
22
0
100.0
.0
“Normality”
“Pathologic”
20
2
90.9
9.1
21
1
95.5
4.5
“Normality”
“Pathologic”
19
3
86.4
13.6
21
1
95.5
4.5
“Normality”
“Pathologic”
20
2
90.9
9.1
22
0
100.0
.0
“Normality”
“Pathologic”
19
3
86.4
13.6
22
0
100.0
.0
Primary Dimensions
Somatization
Obsession-Compulsion
Interpersonal Sensivity
Depressivity
Anxiety
Hostility
Phobic Anxiety
Paranoid Ideation
Psychoticism
General Index of Symptoms
- 305 -
Table 8
Differences in Beck Depression Inventory (BDI) according to the Moment
Moment 1
Moment 2
TG
F-M
M-F
N
Minimum
Maximum
M
SD
N
Minimum
Maximum
M
SD
t
t
t
22
5
33
13.23
8.596
22
0
7
2.45
2.324
6.38***
4.76***
4.99**
BDI
Total
Note. *** p ≤ .001; ** p ≤ .01.
- 306 -
Table 9
Descriptive Analysis of Depression Levels in Beck Depression Inventory (BDI)
according to the Moment
Moment 1
Moment 2
N
%
N
%
Severe Depression
3
13.6
0
.0
Moderate Depression
2
9.1
0
.0
Mild Depression
2
9.1
0
.0
Not Significant
15
68.2
5
22.7
Below Normal
0
.0
17
77.3
- 307 -
Table 10
Differences in the Sociofamily Life Questionnaire dimensions according to the Moment
Moment 1
Moment 2
TG
F-M
M-F
N
Minimum
Maximum
M
SD
N
Minimum
Maximum
M
SD
t
t
t
Employment
17
1.0
3.0
1.771
.641
21
1.0
2.5
1.443
.357
2.62*
-
-
Domestics Functioning
22
1.0
2.8
1.718
.551
22
1.0
2.3
1.591
.424
-
-
-
Social Activ. and Leisure Time
22
1.0
4.7
1.927
.942
22
1.0
2.2
1.436
.330
2.47*
-
-
Relationship - Extended Family
22
1.0
3.3
2.305
.607
22
1.1
3.0
1.805
.564
4.43***
4.10***
-
Relationship with the Spouse
11
1.3
3.0
2.209
.536
14
1.3
2.8
1.679
.408
3.47**
3,47**
-
Relationship with the Children
3
1.3
3.3
2.200
1.015
7
1.3
2.3
1.543
.382
-
-
-
Nuclear Family
6
1.0
2.8
1.733
.797
7
1.0
1.7
1.400
.374
-
-
-
Social Adaptation
22
1.12
3.07
1.996
.573
22
1.15
2.2
1.589
.296
4.54***
4.04***
-
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
- 308 -
Table 11
Differences in the scales of Millon Clinical Multiaxial Inventory (MCMI-II ) according to the Moment
Moment 1
N
Minimum
Moment 2
Maximum
M
SD
N
Minimum
Maximum
M
SD
TG
F-M
M-F
t
t
t
Scales and Validity Index
X – Sincerity
22
15
89
55.73
21.75
22
5
85
42.45
24.15
Y – Desirability
22
28
94
70.50
17.56
22
25
95
67.14
16.86
Z – Modification
22
0
95
36.95
28.71
22
15
70
32.18
1 – Schizoid
22
6
106
60.09
26.60
22
0
73
2 – Phobic
22
0
114
50.91
32.34
22
9
3 – Dependent
22
0
105
49.00
29.80
22
4 – Histrionic
22
4
91
57.18
21.82
5 – Narcissistic
22
22
106
70.23
6A – Antisocial
22
12
117
6B – Agressive-sadic
22
8
7 – Compulsive
22
8A – Passive-aggressive
8B – Self-destructive
2.91**
-
3.59*
-
-
5.89**
16.15
-
-
-
48.45
21.65
-
-
3.25*
94
44.45
23.81
-
-
3.82*
0
78
48.36
23.78
-
-
2.93*
22
20
97
60.68
20.68
-
-
-
23.60
22
23
121
70.14
25.88
-
-
-
61.77
25.38
22
33
116
68.18
19.86
-
-2.17*
-
98
54.18
20.52
22
31
116
62.18
24.90
-
-
-
13
117
74.64
24.24
22
46
93
69.73
12.14
-
-2.79*
-
22
0
109
37.86
31.85
22
0
106
36.32
33.60
-
-
3.65*
22
0
114
38.82
33.2
22
0
93
37.23
24.18
-
-
9.03***
Personality Scales – Basics
(Table continues)
- 309 -
Table 11 (Cont)
Moment 1
N
Minimum
Maximum
S – Schizotypical
22
6
112
C – Borderline
22
2
P – Paranoid
22
A – Anxiety
Moment 2
M
SD
M
DP
TG
F-M
M-F
t
t
t
N
Minimum
Maximum
56.59 28.12
22
21
70
52.64 11.66
-
-
3.68*
90
41.68 28.15
22
5
74
39.05 22.62
-
-
3.00*
6
105
63.41 23.14
22
3
79
49.95 24.15
3.35**
2.60*
-
22
2
95
39.41 27.89
22
1
89
23.36 28.29
2.24*
-
2.92*
H – Hysteriform
22
12
96
45.64 21.60
22
1
62
34.82 23.25
2.18*
-
-
N – Hypomania
22
9
89
52.09 19.82
22
11
82
48.82 17.49
-
-
-
D – Dysthymia
22
2
87
38.64 30.16
22
1
89
18.55 24.04
2.97**
-
3.00*
B – Alcohol Abuse
22
0
91
29.18 25.18
22
1
70
32.05 22.53
-
-
5.30**
T – Drugs Abuse
22
12
85
46.45 19.95
22
3
94
48.45 21.55
-
-
-
SS – Psychotic Thinking
22
0
97
43.95 27.98
22
1
68
40.68 25.08
-
-
2.58*
CC – Major Depression
22
0
107
37.32 30.85
22
0
64
38.00 19.23
-
-
5.14**
PP – Delirious Disorder
22
8
103
62.23 24.47
22
2
71
41.14 25.69
3.98***
3,45**
-
22
0
3
22
0
0
-
-
Personality Disorders
Clinical Disorders – Moderate Intensity
Clinical Disorders – Severe Intensity
Risk Factor
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
.41
.908
.00
.000
2.11*
- 310 -
Table 12
Descriptive Statistics of the intervals of Scales, Validity Index and Risk Factor of Millon
Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
Valid
Questionable
20
2
90.9
9.1
21
1
95.5
4.5
< 35
35-75
> 75
5
12
5
22.7
54.5
22.7
9
12
1
40.9
54.5
4.5
< 35
35-75
> 75
1
12
9
4.5
54.5
40.9
1
13
8
4.5
59.1
36.4
< 35
35-75
> 75
14
6
2
63.6
27.3
9.1
15
7
0
68.2
31.8
.0
0
1
3
17
3
2
77.3
13.6
9.1
22
0
0
100.0
.0
.0
V – Validity
X – Sincerity
Y – Desirability
Z – Modification
Risk Factor
- 311 -
Table 13
Descriptive statistics of the intervals in personality Scales – Basics, Millon Clinical
Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
4
5
9
0
4
18.2
22.7
40.9
.0
18.2
4
10
8
0
0
18.2
45.5
36.4
.0
.0
< 35
35-59
60-74
75-84
≥ 85
7
5
5
3
2
31.8
22.7
22.7
13.6
9.1
7
11
2
0
2
31.8
50.0
9.1
.0
9.1
< 35
35-59
60-74
75-84
≥ 85
6
6
6
2
2
27.3
27.3
27.3
9.1
9.1
4
8
9
1
0
18.2
36.4
40.9
4.5
.0
< 35
35-59
60-74
75-84
≥ 85
3
8
6
4
1
13.6
36.4
27.3
18.2
4.5
3
6
7
4
2
13.6
27.3
31.8
18.2
9.1
< 35
35-59
60-74
75-84
≥ 85
2
5
5
3
7
9.1
22.7
22.7
13.6
31.8
2
6
6
1
7
9.1
27.3
27.3
4.5
31.8
< 35
35-59
60-74
75-84
≥ 85
2
9
5
3
3
9.1
40.9
22.7
13.6
13.6
1 – Schizoid
2 – Phobic
3 – Dependent
4 – Histrionic
5 – Narcissistic
6A – Antisocial
1
4.5
6
27.3
10
45.5
2
9.1
3
13.6
(Table continues)
- 312 -
Table 13 (Cont)
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
2
13
3
3
1
9.1
59.1
13.6
13.6
4.5
2
9
6
1
4
9.1
40.9
27.3
4.5
18.2
< 35
35-59
60-74
75-84
≥ 85
1
3
9
1
8
4.5
13.6
40.9
4.5
36.4
0
5
9
5
3
.0
22.7
40.9
22.7
13.6
< 35
35-59
60-74
75-84
≥ 85
10
8
1
0
3
45.5
36.4
4.5
.0
13.6
12
5
2
0
3
54.5
22.7
9.1
.0
13.6
< 35
35-59
60-74
75-84
≥ 85
11
4
4
1
2
50.0
18.2
18.2
4.5
9.1
12
6
2
1
1
54.5
27.3
9.1
4.5
4.5
6B – Aggressive-sadist
7 – Compulsive
8A – Passive-aggressive
8B – Self-destructive
- 313 -
Table 14
Descriptive statistics of the intervals in personality Disorders Scales of the Millon Clinical
Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
4
7
7
0
4
18.2
31.8
31.8
.0
18.2
2
14
6
0
0
9.1
63.6
27.3
.0
.0
< 35
35-59
60-74
75-84
≥ 85
10
6
4
0
2
45.5
27.3
18.2
.0
9.1
7
10
5
0
0
31.8
45.5
22.7
.0
.0
< 35
35-59
60-74
75-84
≥ 85
3
5
9
2
3
13.6
22.7
40.9
9.1
13.6
8
2
10
2
0
36.4
9.1
45.5
9.1
.0
S – Schizotypical
C – Borderline
P – Paranoid
- 314 -
Table 15
Descriptive statistics of the intervals in Clinical Disorders Scales – Moderate Intensity of
the Millon Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
12
3
4
1
2
54.5
13.6
18.2
4.5
9.1
17
0
4
0
1
77.3
.0
18.2
.0
4.5
< 35
35-59
60-74
75-84
≥ 85
8
9
3
0
2
36.4
40.9
13.6
.0
9.1
10
9
3
0
0
45.5
40.9
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
4
8
8
1
1
18.2
36.4
36.4
4.5
4.5
3
10
8
1
0
13.6
45.5
36.4
4.5
.0
< 35
35-59
60-74
75-84
≥ 85
12
3
3
1
3
54.5
13.6
13.6
4.5
13.6
20
0
0
1
1
90.9
.0
.0
4.5
4.5
< 35
35-59
60-74
75-84
≥ 85
14
5
2
0
1
63.6
22.7
9.1
.0
4.5
9
10
3
0
0
40.9
45.5
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
7
9
4
1
1
31.8
40.9
18.2
4.5
4.5
8
5
8
0
1
36.4
22.7
36.4
.0
4.5
A – Anxiety
H – Hysteriform
N – Hypomania
D – Dysthymia
B – Alcohol Abuse
T – Drugs Abuse
- 315 -
Table 16
Descriptive statistics of the intervals in Clinical Disorders Scales – Severe Intensity of the
Millon Clinical Multiaxial Inventory (MCMI-II) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 35
35-59
60-74
75-84
≥ 85
8
5
7
0
2
36.4
22.7
31.8
.0
9.1
6
9
7
0
0
27.3
40.9
31.8
.0
.0
< 35
35-59
60-74
75-84
≥ 85
10
6
5
0
1
45.5
27.3
22.7
.0
4.5
6
13
3
0
0
27.3
59.1
13.6
.0
.0
< 35
35-59
60-74
75-84
≥ 85
2
6
9
1
4
9.1
27.3
40.9
4.5
18.2
8
6
8
0
0
36.4
27.3
36.4
.0
.0
SS – Psychotic Thinking
CC – Major Depression
PP – Delirious Disorder
- 316 -
Table 17
Differences in Validity Scales of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
N
Minimum
Moment 2
GT
F-M
M-F
Maximum
M
SD
N
Minimum
Maximum
M
SD
t
t
t
-
-
Validity Scales
? – Cannot Say
22
0
8
1.05
2.591
22
0
0
.00
.000
-
L – Lie
22
43
86
59.91
11.02
22
39
83
58.59
11.33
-
2.60*
-
F – Infrequency
22
39
81
54.95
12.27
22
38
59
47.41
6.794
4.19***
3.31**
-
K – Correction
22
34
78
53.18
13.04
22
36
78
59.77
11.46
-2.69*
-2.72*
-
Fb – Back F
19
40
77
53.42
11.95
22
42
70
47.18
6.974
3.58**
2.51*
4.08*
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
- 317 -
Table 18
Differences in Clinical Scales and theirs Subscales of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
GT
F-M
M-F
N
Minimum
Maximum
M
DP
N
Minimum
Maximum
M
DP
t
t
t
Hs – Hypochondriasis
22
37
75
51.73
10.83
20
32
62
50.15
7.376
-
-
-
D – Depression
22
30
81
52.36
13.56
20
36
74
48.90
9.619
-
-
5.56**
D1
19
30
72
50.95
12.83
20
33
64
45.75
8.583
-
-
13.8**
D2
19
30
65
46.21
9.710
20
30
66
49.55
9.179
-
-
-
D3
19
32
90
52.47
12.98
20
32
62
44.95
9.000
-
-
-
D4
19
36
74
49.95
10.11
20
39
71
47.20
7.317
-
-
-
D5
19
34
68
49.63
12.63
20
33
62
44.00
7.574
-
-
12.4**
22
37
78
56.27
10.78
20
31
66
49.20
8.612
-
-
-
Hy1
19
31
63
49.79
9.607
20
36
63
57.20
7.878
-3.23**
-
Hy2
19
30
78
53.00
13.48
20
32
71
52.95
12.19
-
-
Hy3
19
35
84
53.37
14.44
20
35
59
44.55
7.380
-
6.36*
Hy4
19
34
77
51.68
11.49
20
41
63
47.70
5.686
-
-
4.45*
Hy5
19
39
75
56.32
9.827
20
34
75
55.80
11.06
-
-
-
22
42
77
59.91
10.28
20
33
71
54.85
8.798
-
-
-
Pd1
19
43
84
56.63
10.30
20
38
71
49.40
9.029
4.03***
3.31**
-
Pd2
19
37
77
53.68
10.13
20
40
85
55.05
11.29
-
-
-
Pd3
19
34
65
50.00
8.988
20
34
65
58.10
8.233
-4.71***
-3.66**
-5.50*
Pd4
19
37
81
53.47
11.70
20
37
65
47.55
8.476
3.13**
2.35*
5.05*
Pd5
19
32
76
49.37
12.00
20
32
60
43.75
8.589
2.28*
2.27*
-
Clinical Scales
Hy – Hysteria
Pd – Psychopathic Deviate
-3.81**
2.43*
(Table continues)
- 318 -
Table 18 (Cont)
Moment 1
Moment 2
GT
F-M
M-F
N
Minimum
Maximum
M
DP
N
Minimum
Maximum
M
DP
t
t
t
Mf – Masculinity/Femininity
22
43
89
69.68
11.12
22
33
60
48.86
6.483
5.99***
4.84***
6.13**
Pa – Paranoia
22
34
81
54.82
12.66
20
33
67
49.40
10.34
-
-
-
Pa1
19
39
88
56.16
12.42
20
38
80
50.40
11.06
2.24*
-
-
Pa2
19
34
79
51.95
12.43
20
31
65
44.85
9.264
2.80*
-
46.0***
Pa3
19
30
69
49.16
11.97
20
30
69
52.20
12.63
-
-
-
Pt – Psychasthenia
22
31
93
54.73
16.11
20
38
59
47.95
6.778
-
-
Sc – Schizophrenia
22
35
104
58.95
15.59
20
34
65
48.10
6.696
3.60**
2.99**
-
Sc1
19
40
80
58.16
12.45
20
37
57
45.90
7.137
6.08***
5.02***
-
Sc2
19
38
77
55.21
11.45
20
38
70
45.20
9.059
3.17**
2.57*
-
Sc3
19
39
77
48.53
10.15
20
39
58
46.35
5.489
-
-
-
Sc4
19
34
73
49.32
11.93
20
35
61
42.75
6.874
2.49*
-
-
Sc5
19
38
72
48.89
9.723
20
40
69
46.15
7.809
-
-
-
Sc6
19
39
82
50.95
11.66
20
40
61
48.25
6.835
-
-
-
Ma – Hypomania
22
33
70
52.23
8.783
20
38
69
51.05
9.687
-
-
-
Ma1
19
30
58
44.42
9.252
20
30
62
43.30
8.904
-
-
-
Ma2
19
32
65
51.53
10.17
20
31
61
47.25
10.19
-
Ma3
19
35
68
49.74
10.34
20
35
68
54.55
7.708
-
-
-
Ma4
19
37
74
55.26
11.36
20
38
87
53.30
12.19
-
-
-
22
39
87
54.14
12.25
20
31
64
41.60
8.081
5.40***
4.04***
Si1
19
36
73
50.16
10.64
20
35
63
43.65
7.492
3.71**
2.96*
-
Si2
19
37
80
58.21
12.90
20
37
64
46.90
6.103
4.09***
4.23***
-
Si3
19
31
69
48.47
11.60
20
31
56
42.00
8.322
2.39*
-
-
Si – Social Introversion
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
3.40**
3.34*
-
4.45*
- 319 -
Table 19
Differences in Supplementary and Additional Scales of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
GT
F-M
M-F
t
t
N
Minimum
Maximum
M
DP
N
Minimum
Maximum
M
DP
t
A – Anxiety
19
37
68
49.21
10.80
20
32
54
42.05
6.848
3.30**
R – Repression
19
31
69
52.74
10.85
20
32
73
53.30
11.22
-
-
Es – Ego Strength
19
28
68
53.16
12.51
20
41
63
54.30
6.594
-
-
-7.80*
MAC-R – MacAndrew-Revised
19
31
101
51.68
14.75
20
34
80
51.75
12.93
-
-
-5.28*
O-H – Overcontrolled Hostility
19
35
76
53.37
10.22
20
38
83
57.75
11.21
-
-
-
Do – Dominance
19
30
65
47.26
10.48
20
36
68
52.50
8.829
-2.24*
-
-
Re – Social Responsibility
19
30
67
49.11
10.41
20
32
70
55.95
9.611
-2.81*
-3.01**
-
Mt – College Maladjustment
19
32
74
49.53
12.95
20
31
59
43.10
8.239
-
-
12.4**
GM – Masculine Gender Role
19
22
73
54.16
13.81
22
44
70
53.86
7.517
-
4.25***
-16.3***
GF – Feminine Gender Role
19
16
90
39.68
20.13
22
38
71
58.00
9.938
-3.58**
-10.6***
3.32*
19
16
50
31.26
8.530
22
38
70
57.32
9.858
-13.5***
-10.6***
-16.3***
GP – Psychological Gender Role1
19
44
90
62.58
10.77
22
44
71
54.55
7.939
4.61***
4.25***
3.32*
PK – Post-traumatic Stress Disorder
19
36
79
52.79
13.82
20
35
59
44.50
7.323
3.16**
2.23*
5.01*
PS– Post-traumatic Stress Disorder
19
37
76
51.16
12.14
20
34
59
43.05
7.015
4.26***
3.18**
9.25*
MDS – Marital Distress
19
34
72
54.00
10.85
20
35
60
47.45
7.944
3.32**
2.52*
APS – Addiction Potential
19
32
60
45.42
7.221
20
32
63
46.50
9.703
-
-
-
AAS – Addiction Admission
19
40
89
53.05
16.01
20
39
73
49.60
9.632
-
-
-
GB – Biological Gender Role
1
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed in accordance to the Psychological Sex.
2.27*
8.51*
-
-
- 320 -
Table 20
Differences in Content Scales of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
GT
F-M
M-F
t
t
t
N
Minimum
Maximum
M
DP
N
Minimum
Maximum
M
DP
ANX – Anxiety
19
33
77
51.74
13.51
20
35
62
45.15
7.184
FRS – Fears
19
33
66
44.84
9.923
20
33
60
45.20
7.403
-
OBS – Obsessiveness
19
30
67
44.26
10.19
20
36
63
43.60
7.850
-
-2.91*
DEP – Depression
19
34
82
52.89
14.10
20
35
55
42.85
6.319
3.54**
2.61*
HEA – Health Concerns
19
34
76
49.42
11.24
20
39
62
47.95
5.491
-
-
-
BIZ – Bizarre Mentation
19
38
62
48.58
7.698
20
39
63
47.10
7.853
-
-
-
ANG – Anger
19
34
81
45.68
12.22
20
34
66
43.50
8.532
-
-
-
CYN – Cynicism
19
30
74
52.21
12.74
20
31
64
47.20
11.80
ASP – Antisocial Practices
19
32
81
49.11
10.64
20
31
70
45.10
11.83
-
-
-
TPA – Type A
19
34
70
46.37
12.19
20
32
70
46.95
11.59
-
-
-
LSE – Low Self-Esteem
19
34
70
46.00
9.71
20
33
64
40.80
8.377
3.48**
2.67*
-
SOD – Social Discomfort
19
37
78
53.26
11.31
20
36
55
44.45
6.194
4.50***
3.57**
28.0***
FAM – Family Problems
19
36
76
54.00
12.05
20
38
62
48.60
9.616
2.71*
-
-
WRK – Work Interference
19
34
76
47.53
11.87
20
36
62
45.15
6.651
-
-
TRR –Negative Treatment Indicators
19
31
68
48.37
9.610
20
34
55
43.20
5.569
-
-
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
2.28*
2.26*
2.59*
-
6.63*
-
15.1**
2.26*
4.47*
-
- 321 -
Table 21
Descriptive statistics of the intervals in Validity and Inconsistency Scales of the Minnesota
Multiphasic Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 50
50-59
60-69
70-79
≥ 80
5
6
7
3
1
22.7
27.3
31.8
13.6
4.5
4
9
4
4
1
18.2
40.9
18.2
18.2
4.5
< 50
50-59
60-64
65-79
80-100
8
7
4
1
2
36.4
31.8
18.2
4.5
9.1
14
8
0
0
0
63.6
36.4
.0
.0
.0
< 50
50-59
60-70
> 70
10
5
4
3
45.5
22.7
18.2
13.6
4
5
11
2
18.2
22.7
50.0
9.1
< 50
50-64
65-79
80-100
>100
9
6
4
0
0
40.9
27.3
18.2
.0
.0
18
3
1
0
0
81.8
13.6
4.5
.0
.0
22
100.0
22
100.0
22
100.0
22
100.0
L – Lie
F – Infrequency
K – Correction
Fb – Back F
TRIN – True Response Inconsistency
< 14 (Valid)
VRIN – Variable Response Inconsistency
≤ 14 (Valid)
- 322 -
Table 22
Descriptive statistics of the intervals in Clinical Scales of the Minnesota Multiphasic
Personality Inventory – 2 (MMPI-2) according to the Moment
Moment 1
Moment 2
N
%
N
%
< 40
40-59
60-80
> 80
4
14
4
0
18.2
63.6
18.2
.0
1
17
2
0
4.5
77.3
9.1
.0
< 40
40-59
60-70
> 70
4
11
5
2
18.2
50.0
22.7
9.1
4
12
3
1
18.2
54.5
13.6
4.5
< 40
40-59
60-80
> 80
2
12
8
0
9.1
54.5
36.4
.0
3
15
2
0
13.6
68.2
9.1
.0
< 40
40-59
60-75
> 75
0
11
10
1
.0
50.0
45.5
4.5
2
14
4
0
9.1
63.6
18.2
.0
< 40
40-59
60-75
> 75
0
3
12
7
.0
13.6
54.5
31.8
4
17
1
0
18.2
77.3
4.5
.0
< 35
35-44
45-49
50-59
60-70
> 70
2
2
3
8
5
2
9.1
9.1
13.6
36.4
22.7
9.1
1
4.5
6
27.3
4
18.2
5
22.7
4
18.2
0
.0
(Table continues)
Hs – Hypochondriasis
D – Depression
Hy – Hysteria
Pd – Psychopathic Deviate
Mf – Masculinity – Femininity
Pa – Paranoia
- 323 -
Table 22 (Cont)
Moment 1
Moment 2
N
%
N
%
< 40
40-59
60-75
> 75
5
9
6
2
22.7
40.9
27.3
9.1
4
16
0
0
18.2
72.7
.0
.0
< 40
40-59
60-75
> 75
2
10
8
2
9.1
45.5
36.4
9.1
1
18
1
0
4.5
81.8
4.5
.0
< 40
40-59
60-69
70-80
> 80
2
17
2
1
0
9.1
77.3
9.1
4.5
.0
5
11
4
0
0
22.7
50.0
18.2
.0
.0
< 40
40-59
60-75
> 75
2
13
5
2
9.1
59.1
22.7
9.1
9
10
1
0
40.9
45.5
4.5
.0
Pt – Psychasthenia
Sc – Schizophrenia
Ma – Hypomania
Si – Social Introversion
- 324 -
Table 23
Descriptive statistics of the intervals of Supplementary and Additional Scales of the
Minnesota Multiphasic Personality Inventory – 2 (MMPI-2)according to the Moment
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
6
11
2
27.3
50.0
9.1
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
3
14
2
13.6
63.6
9.1
2
15
3
9.1
68.2
13.6
< 40
40-65
> 65
3
14
2
13.6
63.6
9.1
0
20
0
.0
90.9
.0
< 50
50-64
≥ 65
11
7
1
50.0
31.8
4.5
11
5
4
50.0
22.7
18.2
< 40
40-65
> 65
1
16
2
4.5
72.7
9.1
1
14
5
4.5
63.6
22.7
< 40
40-65
> 65
6
13
0
27.3
59.1
.0
1
17
2
4.5
77.3
9.1
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
1
17
2
4.5
77.3
9.1
< 40
40-65
> 65
5
11
3
22.7
50.0
13.6
7
13
0
31.8
59.1
.0
< 40
40-65
> 65
16
3
0
72.7
13.6
.0
2
9.1
16
72.7
4
18.2
(Table continues)
A – Anxiety
R – Repression
Es – Ego Strength
MAC-R – MacAndrew-Revised
O-H – Overcontrolled Hostility
Do – Dominance
Re – Social Responsibility
Mt – College Maladjustment
GB – Biologic Gender Role1
- 325 -
Table 23 (Cont)
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
0
13
6
.0
59.1
27.3
0
19
3
.0
86.4
13.6
< 40
40-65
> 65
6
9
4
27.3
40.9
18.2
8
12
0
36.4
54.5
.0
< 40
40-65
> 65
5
12
2
22.7
54.5
9.1
10
10
0
45.5
45.5
.0
< 40
40-65
> 65
1
14
4
4.5
63.6
18.2
4
16
0
18.2
72.7
.0
< 40
40-65
> 65
4
15
0
18.2
68.2
.0
6
14
0
27.3
63.6
.0
< 40
40-65
> 65
6
10
3
27.3
45.5
13.6
5
13
2
22.7
59.1
9.1
GB – Psychological Gender Role1
PK – Posttraumatic Stress Disorder
PS– Posttraumatic Stress Disorder
MDS – Marital Distress
APS – Addiction Potential
AAS – Addiction Admission
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed
in accordance to the Psychological Sex.
- 326 -
Table 24
Descriptive statistics of the intervals of Content Scales of the Minnesota Multiphasic
Personality Inventory – 2 (MMPI-2) according to the Momen
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
5
10
4
22.7
45.5
18.2
4
18
0
18.2
72.7
.0
< 40
40-65
> 65
8
10
1
36.4
45.5
4.5
5
15
0
22.7
68.2
.0
< 40
40-65
> 65
7
11
1
31.8
50.0
4.5
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
4
11
4
18.2
50.0
18.2
9
11
0
40.9
50.0
.0
< 40
40-65
> 65
5
12
2
22.7
54.5
9.1
2
18
0
9.1
81.8
.0
< 40
40-65
> 65
4
15
0
18.2
68.2
.0
4
16
0
18.2
72.7
.0
< 40
40-65
> 65
8
10
1
36.4
45.5
4.5
10
9
1
45.5
40.9
4.5
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
7
13
0
31.8
59.1
.0
< 40
40-65
> 65
5
13
1
22.7
59.1
4.5
8
36.4
11
50.0
1
4.5
(Table continues)
ANX – Anxiety
FRS – Fears
OBS – Obsessiveness
DEP – Depression
HEA – Health Concerns
BIZ – Bizarre Mentation
ANG – Anger
CYN – Cynicism
ASP – Antisocial Practices
- 327 -
Table 24 (Cont)
Moment 1
Moment 2
N
%
N
%
< 40
40-65
> 65
10
7
2
45.5
31.8
9.1
8
11
1
36.4
50.0
4.5
< 40
40-65
> 65
6
12
1
27.3
54.5
4.5
13
7
0
59.1
31.8
.0
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
8
12
0
36.4
54.5
.0
< 40
40-65
> 65
3
13
3
13.6
59.1
13.6
6
14
0
27.3
63.6
.0
< 40
40-65
> 65
8
9
2
36.4
40.9
9.1
5
15
0
22.7
68.2
.0
< 40
40-65
> 65
4
14
1
18.2
63.6
4.5
7
13
0
31.8
59.1
.0
TPA – Type A
LSE – Low Self-Esteem
SOD – Social Discomfort
FAM – Family Problems
WRK – Work Interference
TRR – Negative Treatment Indicators
- 328 -
Table 25
Correlation Matrix of variables from SCL-90, BDI, QVSF and MMPI-2 according to Moment 1
Moment 1
(1)
1 – SCL-90 Interpersonal Sensitivity
.52*
3 – Employment QVSF
.65**
-
5 – Social Activities and Leisure Time QVSF
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
-
2 – Total BDI
4 – Domestics Tasks QVSF
(2)
.56**
.53*
-
-
-
-
.61*
.44*
.76***
6 – Extended Family QVSF
-
7 – Relationship with the Spouse QVSF
-
-
-
-
-
-
-
8 – Relationship with the Children QVSF
-
-
-
-
-
-
-
-
9 – Nuclear Family QVSF
-
-
.98**
-
-
-
.85*
-
-
.70***
.76***
.67***
.88***
.78***
.81***
-
.85*
-
-
-
-
-
-
-
-
.85*
-
.57*
-
.65***
.44*
.69*
-
-
.69***
-
-
-
-
-
-
-
-.49*
-.66*
-
-
-.74***
-
-
.43*
10 – Social Adaptation QVSF
11 – Masculinity/Femininity MMPI-2
12 – Social Introvertion MMPI-2
.50*
.59**
.61**
-
.61**
.61**
-
13 – Social Responsibility MMPI-2
-
-
-
14 – Biological Gender Role1 MMPI-2
-
-.52*
-.62*
15 – Psychological Gender Role MMPI-2
-
-
-
-
-
-
-
-
16 – Antisocial Practices MMPI-2
-
-
-
-
-
-
-
-
.99**
.51*
-
.63*
-
.68***
-
-
-
.98**
18 – Social Discomfort MMPI-2
-
.51*
.52*
.57*
-
-
-
-
.66**
19 – Work Interference MMPI-2
.50*
-
-
-
-
-
-
-
.93*
.56**
-
.51*
-
-
.72***
-
-
-
-
.66**
1
17 – Low Self-Esteem MMPI-2
20 – Negative Treatment Indicators MMPI-2
.68**
-.74***
-.63**
.63**
(Table continues)
- 329 -
Table 25 (Cont)
Moment 1
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
1 – Interpersonal Sensivity SCL-90
2 – Total BDI
3 – Employment QVSF
4 – Domestics Tasks QVSF
5 – Social Activities and Leisure Time QVSF
6 – Extended Family QVSF
7 – Relationship with the Spouse QVSF
8 – Relationship with the Children QVSF
9 – Nuclear Family QVSF
10 – Social Adaptation QVSF
11 – Masculinity/Femininity MMPI-2
-
12 – Social Introvertion MMPI-2
-
-
13 – Social Responsibility MMPI-2
-
-
-
-
-
-
-
15 – Psychological Gender Role MMPI-2
-
-
.49*
-
-
16 – Antisocial Practices MMPI-2
-
-
-.52*
-
-
-
17 – Low Self-Esteem MMPI-2
-
.63**
-.53*
-.52*
-
-
-
18 – Social Discomfort MMPI-2
-
.89***
-
-.50*
-
-
-
-
19 – Work Interference MMPI-2
-
.63**
-
-
-
.85***
-
-
20 – Negative Treatment Indicators MMPI-2
-
-.46*
-
-
.85***
-
.84***
1
14 – Biological Gender Role MMPI-2
1
-
-.61**
-.46*
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed in accordance to the Psychological Sex.
-
- 330 -
Table 26 – Correlation Matrix of variables of SCL-90, BDI, QVSF and MMPI-2 according to Moment 2
Moment 2
(1)
1 – Interpersonal Sensitivity SCL-90
2 – Total BDI
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
.45*
-
3 – Employment QVSF
-
-
-
4 – Domestics Tasks QVSF
-
.48*
-
-
5 – Social Activities and Leisure Time QVSF
-
-
-
-
6 – Extended Family QVSF
-
-
-
.45*
7 – Relationship with the Spouse QVSF
-
-
-
-
-
-
-
8 – Relationship with the Children QVSF
-
-
-
-
-
-
-
-
9 – Nuclear Family QVSF
-
-
-
-
-.80*
-
-
-
-
10 – Social Adaptation QVSF
-
-
.85***
-
-
-
-
11 – Masculinity/Femininity MMPI-2
-
-
-
-
-
-
-.65*
-
-
-
12 – Social Introvertion MMPI-2
-
-
-
-
-
-
-
.91**
-
-
13 – Social Responsibility MMPI-2
-
-
-
-
-
-
-
-
-
-
-
-.51*
-
-
-
-
-
-
-.51*
15 – Psychological Gender Role MMPI-2
-
-
-
-
-
-
-
.79*
-
-
16 – Antisocial Practices MMPI-2
-
-
-
-
-
-
-
-
1
14 – Biological Gender Role MMPI-2
1
17 –Low Self-esteem MMPI-2
.52**
.64**
.66***
.54**
.61**
-
-.62**
.62**
.44*
-
-
-
-
.50*
-
.79*
-
.54*
18 – Social Discomfort MMPI-2
-
-
-
-
.49*
-
-
.83*
-
.46*
19 – Work Interference MMPI-2
-
-
-
-
-
-
.62*
-
-
-
20 – Negative Treatment Indicators MMPI-2
-
-
-
.49*
-
-
-
-
21 – PRS Duration
-
-.59*
-
-
-
-
-
-
.64**
-
.66**
(Table continues)
-
- 331 -
Table 26 (Cont)
Moment 2
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
1 – Interpersonal Sensivity SCL-90
2 – Total BDI
3 – Employment QVSF
4 – Domestics Tasks QVSF
5 – Social Activities and Leisure time QVSF
6 – Extended Family QVSF
7 – Relationship with the Spouse QVSF
8 – Relationship with the Children QVSF
9 – Nuclear Family QVSF
10 – Social Adaptation QVSF
11 – Mas./Fem. MMPI-2
-
12 – Social Introvertion MMPI-2
-
-
13 – Social Responsibility MMPI-2
-
-
14 – Biological Gender Role MMPI-2
-
-
.60**
-
15 – Psychological Gender Role MMPI-2
-
-
.44*
-
-
16 – Antisocial Practices MMPI-2
-
-
-.82***
-.63**
-
-
17 – Low Self-esteem MMPI-2
-
.61**
-
-.69***
-
.55*
18 – Social Discomfort MMPI-2
-
.58**
-
-
-
-
.57**
-
19 – Work Interference MMPI-2
-
-
-
-.60**
-
.67***
.70***
-
-
20 – Negative Treatment Indicators MMPI-2
-
-
-
-.54**
-
.56**
.59**
-
.77***
-
.56*
-
.57*
-
-
-.61*
-
-
-
1
21 – PRS Duration
-
-
-
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed in accordance to the Psychological Sex.
-
- 332 -
Table 27 – Correlation Matrix of variables from SCL-90, BDI, QVSF and of MMPI-2 according to the Moment
Moment 1
(1)
Moment 2
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
1 – Interpersonal Sensivity SCL-90
-
2 – Total BDI
-
-
3 – Employment QVSF
-
.48*
.48*
4 – Domestics Tasks QVSF
-
-
-
.52*
5 – Social Activities and Leisure Time QVSF
-
-
-
-
6 – Extended Family QVSF
-
.45*
-
7 – Relationship with the Spouse QVSF
-
-
-
-
-
-
-
.87*
-
-
.76*
-
.76*
-
-
-
-
-
-
.53*
-
-
.93**
8 – Relationship with the Children QVSF
.94**
(10)
.88*
.61**
.50*
.46*
.92**
.48*
.59**
.51*
.55**
.59**
.67***
.55**
.81*
9 – Nuclear Family QVSF
-
-
-
10 – Social Adaptation QVSF
-
.53*
.52*
11 – Masculinity/Femininity MMPI-2
-
-
-
-
-
-
-
-
-.88*
-
.54*
-
.51*
-
-
-
.65*
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-.52*
-
-
-
-.97***
15 – Psychological Gender Role MMPI-2
-
-
-
-
-
-
-
-
-
-
16 – Antisocial Practices MMPI-2
-
-
-
-
-
-
-
-
.85*
-
17 – Low Self-esteem MMPI-2
-
.47*
-
-
-
.69*
-
.91*
.68***
18 – Social Discomfort MMPI-2
-
-
-
-
-
.67*
-
-
.49*
19 – Work Interference MMPI-2
.48*
-
-
.45*
.66**
-
-
-
-
.64**
20 – Negative Treatment Indicators MMPI-2
-
-
-
.65**
.74***
.53*
-
-
-
.69***
21 – PRS Duration
-
-
-
-
-
-
-
-
12 – Social Introvertion MMPI-2
13 – Social Responsibility MMPI-2
1
14 – Biological Gender Role MMPI-2
1
.58**
-
.62**
.59**
-
-
.70***
-.57**
(Table continues)
- 333 -
Table 27 (Cont)
Moment 1
Moment 2
(11)
(12)
.78**
.96***
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
1 – Interpersonal Sensivity SCL-90
2 – Total BDI
3 – Employment QVSF
4 – Domestics Tasks QVSF
5 – Social Activities and Leisure TimeQVSF
6 – Extended Family QVSF
7 – Relationship with the Spouse QVSF
8 – Relationship with the Children QVSF
.89*
.78*
9 – Nuclear Family QVSF
-.71***
10 – Social Adaptation QVSF
11 – Mas./Fem. MMPI-2
.52*
-.70***
12 – Social Introvertion MMPI-2
-.48*
-
.62**
-
.60*
-
-
.51*
.56*
15 – Psychological Gender Role MMPI-2
-
-
-
-
16 – Antisocial Practices MMPI-2
-
-
-.65**
17 – Low Self-esteem MMPI-2
-
.78***
18 – Social Discomfort MMPI-2
-
.61**
19 – Work Interference MMPI-2
-
.52*
20 – Negative Treatment Indicators MMPI-2
-
-
21 – PRS Duration
-
-
13 – Social Responsibility MMPI-2
1
14 – Biological Gender Role MMPI-2
1
-.75***
-.54*
-.69**
-.54*
-.49*
-.62**
-.52*
-.61**
.62**
-
-
.78***
.60**
.83***
.66**
-.53*
-.60*
-
-
.74***
.64**
.78***
-
-
-
-
-
-.60**
-
-
.57*
-
.66**
.78***
-
-.53*
-
-
.61**
-
.60*
.81***
-
-
-
-
-
-
-
-.62**
.70**
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed in accordance to the Psychological Sex.
-
-
- 334 -
Table 28 – Significant Differences between F-M and M-F on the different scales in Moment 1 and in Moment 2
Moment 1
F-M
Moment 2
M-F
F-M
M1
M2
t
t
M-F
N
M
DP
N
M
DP
N
M
DP
N
M
DP
Somatization
16
.490
.476
6
1.235
.869
16
.436
.468
6
.455
.221
-2,60*
-
Obsession-Compulsion
16
.731
.604
6
1.583
.966
16
.619
.453
6
.933
.513
-2.50*
-
Depressivity
16
.770
.757
6
1.623
1.078
16
.396
.333
6
.702
.413
-2.10*
-
Paranoid Ideation
16
.800
.700
6
1.643
1.036
16
.508
.591
6
.664
.526
-2.21*
-
Psychoticism
16
.456
.475
6
1.333
.948
16
.200
.242
6
.467
.344
-2.92**
-
Death Thinking
16
1.13
1.025
6
2.17
.753
.13
.342
.516
-2.26*
-
16
1.38
1.204
6
2.33
1.033
.31
.602
6
6
.33
Sleep disturbances
16
16
1.00
.894
-
-2.09*
Feelings of guilt
16
.81
1.167
6
1.17
1.169
16
.31
.704
6
1.17
.983
-
-2.28*
General Symptoms Index
16
.639
.491
6
1.440
.959
16
.374
.313
6
.577
.313
-2.61*
-
X – Sincerity
16
49.38
20.48
6
72.67
15.96
16
40.88
25.74
6
46.67
20.79
-2.50*
-
Y – Desirability
16
25.94
21.08
6
66.33
26.56
16
32.00
14.35
6
32.67
21.85
-3.74***
-
2 – Phobic
16
40.38
28.10
6
79.00
26.86
16
43.38
24.08
6
47.33
25.07
-2.90**
-
3 – Dependent
16
38.50
25.52
6
77.00
21.96
16
43.69
25.23
6
60.83
14.50
-3.26**
-
7 – Compulsive
16
81.81
21.56
6
55.50
21.63
16
68.63
11.96
6
72.67
13.23
2.55*
-
8A – Passive-aggressive
16
26.19
23.80
6
69.00
31.02
16
35.88
31.18
6
37.50
42.70
-3.47**
-
8B – Self-destructive
16
24.44
23.86
6
77.17
22.27
16
36.06
25.95
6
40.33
20.49
-4.69***
-
S – Schizotypical
16
48.50
26.72
6
78.17
20.27
16
51.38
13.01
6
56.00
6.663
-2.45*
-
C – Borderline
16
30.81
23.75
6
70.67
15.82
16
36.75
23.66
6
45.17
20.21
-3.78***
-
SCL-90
MCMI-II
(Table continues)
- 335 -
Table 28 (Cont)
Moment 1
F-M
Moment 2
M-F
F-M
M1
M2
t
t
M-F
N
M
DP
N
M
DP
N
M
DP
N
M
DP
H – Hysteriform
16
39.38
21.36
6
62.33
11.43
16
30.19
24.40
6
47.17
15.29
-2.48*
-
N – Hypomania
16
22.07
6
61.50
6.473
16
47.13
18.75
6
53.33
14.00
-2.12*
-
D – Dysthymia
16
48.56
29.63
24.68
6
62.67
32.24
16
16.81
21.84
6
23.17
31.01
-2.58*
-
B – Alcohol Abuse
16
20.94
23.74
6
51.17
13.24
16
31.75
24.68
6
32.83
17.41
-2.92**
-
T – Drugs Abuse
16
40.06
18.71
6
63.50
11.88
16
48.38
23.56
6
48.67
16.91
-2.84**
-
SS – Psychotic Thinking
16
36.50
28.35
6
63.83
14.97
16
38.63
26.42
6
46.17
22.31
-2.23*
-
CC – Major Depression
16
26.19
26.30
6
67.00
21.65
16
42.31
13.42
6
26.50
28.20
-3.38**
-
L – Lie
16
63.94
9.801
6
49.17
5.636
16
59.50
11.94
6
56.17
10.07
3.45**
-
Hs – Hypochondriasis
16
49.00
10.23
6
59.00
9.571
15
52.00
6.071
5
44.60
8.877
-
D – Depression
16
47.06
10.45
6
66.50
10.71
15
49.73
9.588
5
46.40
10.36
-3.86***
-
Hy – Hysteria
16
52.69
9.046
6
65.83
9.559
15
49.93
8.556
5
47.00
9.381
-2.99**
-
Mf – Masculinity/Femininity
16
65.13
8.936
6
81.83
6.047
15
50.56
4.381
5
44.33
9.223
-4.20***
Pa – Paranoia
16
50.94
11.17
6
65.17
11.04
15
49.13
11.53
5
50.20
6.458
-2.67*
-
Pt – Psychasthenia
16
49.75
13.34
6
68.00
16.54
15
48.40
7.239
5
46.60
5.639
-2.70*
-
Sc – Schizophrenia
16
54.31
11.72
6
71.33
18.84
15
46.93
5.625
5
51.60
9.044
-2.57*
-
ANX – Anxiety
15
47.67
11.59
4
67.00
8.602
15
45.00
6.719
5
45.60
9.317
-3.09**
-
FRS – Fears
15
41.20
6.560
4
58.50
8.660
15
44.20
6.450
5
48.20
9.985
-4.41***
-
OBS – Obsessiveness
15
41.60
8.244
4
54.25
11.70
15
42.93
6.628
5
45.60
11.50
-2.51*
-
HEA – Health Concerns
15
46.60
9.869
4
60.00
10.71
15
48.20
5.401
5
47.20
6.340
-2.38*
-
Es – Ego Strength
15
57.13
10.08
4
38.25
9.465
15
55.27
6.638
5
51.40
6.189
3.36**
-
MMPI-2
2.11*
2.18*
(Table continues)
- 336 -
Table 28 (Cont)
Moment 1
F-M
Moment 2
M-F
F-M
M2
M-F
N
M
DP
N
M
DP
N
M
DP
N
M
DP
t
t
GM – Masculine Gender Role
15
59.73
8.336
4
33.25
9.069
16
52.69
5.425
6
57.00
11.52
5.56***
-
GF – Feminine Gender Role
15
30.73
8.631
4
73.25
13.40
16
57.44
9.578
6
59.50
11.66
-7.83***
-
1
15
59.73
8.336
4
73.25
13.40
16
52.69
5.425
6
59.50
11.66
-2.55*
-
D3 – Depression
15
48.40
8.634
4
67.75
16.42
15
46.53
8.782
5
40.20
8.786
-3.29**
-
D5 – Depression
15
47.27
13.25
4
58.50
2.380
15
44.40
8.016
5
42.80
6.723
-3.10**
-
Pa1 – Paranoia
15
53.25
10.55
4
67.00
14.45
15
50.73
11.70
5
49.40
10.02
-2.15*
-
Sc3 – Schizophrenia
15
46.20
8.152
4
57.25
13.38
15
45.53
5.012
5
48.80
6.723
-2.11*
-
GP – Psychological Gender Role
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
1
M1
At M1 the Evaluation was performed according to the Biological Sex, and at M2 the Evaluation was performed in accordance to the Psychological Sex
- 337 -
Table 29
Descriptive statistics of the intervals in the Scales Gender Role of the Minnesota
Multiphasic Personality Inventory – 2 (MMPI-2) according to the type of Evaluation
and the Moment
Moment 1
GBb – Biological Gender Role
Evaluation according to biological sex
< 40
40-65
> 65
GPb – Psychological Gender Role
Evaluation according to biological sex
< 40
40-65
> 65
GBp – Biological Gender Role
Evaluation according to psychological sex
< 40
40-65
> 65
GPp – Psychological Gender Role
Evaluation according to psychological sex
< 40
40-65
> 65
Moment 2
N
%
N
%
16
3
0
72.7
13.6
.0
20
2
0
90.9
9.1
.0
0
13
6
.0
59.1
27.3
0
8
14
.0
36.4
63.6
-
-
2
16
4
9.1
72.7
18.2
-
-
0
19
3
.0
86.4
13.6
- 338 -
Table 30
Differences in the Scales of Gender Role of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the type of
evaluation and Moment
(M) Confidence Intervals
GB1b - Biologic Gender Role
M1 – Evaluation according to biological sex
GP1b - Psychological Gender Role
M1 – Evaluation according to biological sex
GB2p - Biologic Gender Role
M2 – Evaluation according to psychological sex
GP2p - Psychological Gender Role
M2 – Evaluation according to psychological sex
GB2b - Biologic Gender Role
M2 – Evaluation according to biological sex
GP2b - Psychological Gender Role
M2 – Evaluation according to biological sex
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
*** p ≤ .001
** p ≤ .01
* p ≤ .05
24 - 39
26 - 37
27 - 35
53 - 72
55 - 70
57 - 68
49 - 67
52 - 65
54 - 63
48 - 60
49 - 58
50 - 57
35 - 50
37 - 48
38 - 46
60 - 73
62 - 71
63 - 70
GB1b
GP1b
GB2p
GP2p
GB2b
GP2b
***
***
***
**
***
-
***
***
-
-
**
*
**
***
***
- 339 -
Table 31
Correlation Matrix of the variables Gender Role of the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) according to the
type of evaluation and Moment
r
GB1b
GB1b – Biologic Gender Role
M1 – Evaluation according to biological sex
GP1b – Psychological Gender Role
M1 – Evaluation according to biological sex
GB2p - Biologic Gender Role
M2 – Evaluation according to psychological sex
GP2p - Psychological Gender Role
M2 – Evaluation according to psychological sex
GB2b - Biologic Gender Role
M2 – Evaluation according to biological sex
GP2b - Psychological Gender Role
M2 – Evaluation according to biological sex
Note. *** p ≤ .001; ** p ≤ .01; * p ≤ .05.
GP1b
GB2p
GP2p
GB2b
GP2b
-
-
-
.56*
-
-
.48*
-
.62**
.49*
.75***
-
-
.88***
-
-
-
.94***
-
-
-