Psychological Tests: The Uninvited Guest

How might one account for the discrepancies between the results of the clinical interview. which agreed with the patient's self reports that Tina was stable and rehabilitated post SRS, and the results of the psychological testing? Was this an example of a folie a deux between therapist and patient? Or were the results of the psychological testing being taken too seriously?

The evaluation process, we may recall, was also not without some element of clinical disagreement. While the social worker was confused as to whether Tina was "homosexual" or "transsexual," the psychiatrist was convinced she was a "true transsexual." The shift from a state of confusion regarding Tina's gender identity to a certain belief that she was a "true transsexual" was made almost entirely on the basis of clinical interview material. This move also involved a shift in pronouns in which the evaluators now called the patient "he." The MMPI report, which I can only regard as inadequately interpreted, and the recommendation "ill advised" against psychological intervention may have been guided more by the consultant's prior conceptions of homosexuality and transsexualism than by the clinical facts. At that point in Tina's evaluation no one requested complete psychological testing.

Tina's diagnostic evaluation posed some interesting yet common problems in the diagnosis of female transsexualism. The evaluation suggested how differing clinical views are resolved less out of an appreciation for the clinical data than out of deference to one's clinical biases and to the opinion of the primary or referring clinician. Above all, the question of whether Tina was a good candidate for SRS dominated the clinical inquiry. Tina's lack of noxious personality traits, coupled with the fact that she was not sociopathic, always reinforced the idea that she was a good surgical candidate. No one raised the question that her "health" and "stability" might suggest that she be provided more intensive psychotherapy in lieu of gender reassignment. One might argue that if the clinicians were interested in supporting her "health" I and "stability," then SRS would have been contraindicated. The paradox is that gender clinics are usually organized in such a way as to find true transsexuals to refer for SRS and that the "healthier" female gender patients are the ones referred for SRS.

In the process of arriving at Tina's diagnosis and subsequent treatment, two clinical procedures seemed crucial: (1) Tina's immediate evaluation by the surgeon (a communication which surely supported the patient's fantasy that SRS was a viable solution to her problems, thereby increasing her demands for SRS); and (2) Tina's referral for hormone therapy (which may have communicated the therapist's hopelessness with regard to reconstructive psychotherapy). The implication was that, if therapy was useful at all, it could only be adjunctive to SRS, not curative in and of itself. Of interest was the fact that two males, the psychiatrist and the social worker, with different levels of education and training, had entirely different views of the case, with the medically trained clinician treating the patient's complaints medically.

The lack of appreciation that psychological testing could shed light on Tina's clinical condition was rather remarkable given the important role that psychological testing has traditionally played in the diagnostic process (Schafer, 1948) and the value it had for some members of the clinic. Two papers on the psychological testing of transsexuals supported the view of the importance of utilizing testing in the evaluation process (McCully, 1963; Hill, 1980). In trying to account for this discrepancy, I was struck by several lines of development among transsexual researchers. The most striking fact was that here we have a primary psychological disorder, transsexualism, which was being treated mostly by individuals with little or no psychiatric/psychological training, some of whom did not even have the clinical training to pose the necessary questions. This was not, however, the case in Tina's evaluation (which made the process all the more confusing). (see PROPOSITION 1: THE SO CALLED "STABLE" COURSE OF FEMALE TRANSSEXUALISM PART XII)