Biology of Gender Identification (Psychology)

Transexuals’ Recognition of Emotions as Measured by the FEEL-Test

Henrik Kessler, Dr.med Daniela Michallik, Dr.med Friedemann Pfäfflin, MD

ABSTRACT. The study investigates the ability of transsexuals (TS) to recognize facially ex- pressed basic emotions. It was hypothesized that, due to their discomfort in their gender role, this ability might be diminished in TS. In addition it was expected that emotion recognition improves during the course of transgendering, e.g., after having started the Real-life Experience (RLE) which regularly reduces stress levels. Finally it was hypothesized that TS do better in recognizing facial emotions when the person showing them has their desired sex and gender. To test these hy- potheses the FEEL-test (Facially Expressed Emotion Labelling) was used. Forty-seven TS and 55 non-transsexual controls matched for age and sex were included in the study. The first hypothesis was confirmed. As regards the second hypothesis, no differences could be found between the groups at different stages in the transition between the two genders. The third hypothesis was also rejected: TS recognized facially expressed basic emotions from male and female stimuli independ- ently of their desired sex. doi:10.1300/J485v09n02_02 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress. com> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Transsexualism, emotional intelligence, transgenderism

INTRODUCTION

Transsexualism as an axis-I diagnosis was first introduced into the Diagnostic and Statisti- cal Manual of the American Psychiatric Asso- ciation in its third edition (DSM-III, APA, 1980). In DSM-III-R (APA, 1987) it was re- categorized as an axis-II diagnosis. In DSM-IV (APA, 1994) it was substituted by the broader diagnostic category Gender Identity Disorder, again an axis-I diagnosis. The diagnosis is still used in the International Classification of Dis- eases (ICD-10, WHO, 1991), but transgender

phenomena have long escaped the straight- jacket of psychiatric classifications (Ekins, 1997, Ekins & King, 1996, 1999, 2001). Never- theless, transsexualism may still be regarded as the most extreme form of transgenderism, and it is worthwhile to deepen the understanding of these phenomena. Most of the medical research on transsexualism focuses either on trying to explain its etiology or on treatment techniques and their outcome. Anthropological, historical, sociological and cultural research is more interested in describing the varieties of its expression.

Henrik Kessler, Dr.med, Daniela Michallik, Dr.med, Friedemann Pfäfflin, MD, are affiliated with Forensic Psy- chotherapy, University of Ulm, Am Hochstraess 8, D-89081 Ulm, Germany.

Address correspondence to: Henrik Kessler (E-mail: [email protected]), or Friedemann Pfäfflin (E-mail: [email protected]), at the above address.

International Journal of Transgenderism, Vol. 9(2) 2006 Available online at http://ijt.haworthpress.com

© 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J485v09n02_02 9

The study presented here is more in line with the latter branch of research than with the one men- tioned first. It investigates certain aspects of emotional intelligence (EI) as defined by Salovey and Mayer (1990) and specifically emotion regulation behavior in social interac- tions. One definition of emotional intelligence is “the ability to process emotional information, particularly as it involves the perception, as- similation, understanding, and management of emotion” (Mayer & Cobb, 2000, p. 164). The study focuses on the perception side of EI and in particular on the ability to properly identify emotional facial cues displayed by other per- sons. As transsexuals reject their biological sex and prefer the gender role of the opposite sex, we hypothesized that this might influence their ability to read and identify emotional facial ex- pressions of others depending on the state they have reached in their own process of trans- gendering on the one hand and on the gender role of the other persons. The recently devel- oped FEEL-test (Facially Expressed Emotion Labeling; Kessler et al., 2002, see below) was used to measure the ability of the transsexual subjects and of non-transsexual controls to identify specific emotional facial expressions.

HYPOTHESES

According to ICD-10 as well as DSM-IV the most outstanding characteristics for trans- sexualism and gender identity disorders re- spectively are (1) a strong and persistent cross-gender identification and (2) a persistent discomfort with the own sex and a sense of in- appropriateness in the gender role of that sex. We hypothesized that the persistent discomfort results in a diminished ability to read and prop- erly identify facial emotional expressions of others. The first hypothesis is: Transsexuals recognize facially displayed basic emotions less precisely than controls.

According to the Harry Benjamin Interna- tional Gender Dysphoria Association’s (2001) Standards of Care for Gender Identity Disor- ders the real-life Experience (RLE) is an impor- tant period in the treatment and transitional pro- cess of transsexuals. Adopting the desired gender role usually markedly diminishes the formerly experienced distress. With more

self-acceptance and at the same time greater so- cial acceptance, the ability to recognize the facially expressed emotions of others should improve. Hence the second hypothesis: Identi- fication of facial emotional expression is better in transsexuals having started the Real-life Experience as compared to those who have not yet started.

The strong desire to be a member of the op- posite sex may induce a perceptional bias. Al- though as of yet nothing has been reported in the literature, it is feasible that transsexuals are more sensitive to emotional signals of members of their desired sex and gender than to signals of members of their biological sex. This bias may partly depend on the degree to which the subjects consider themselves to be masculine or feminine, as measured by the German ver- sion of the Bem Sex-Role-Inventory (BSRI) (Schneider-Düker, 1978, Schneider-Düker & Kohler 1988). The third hypothesis is thus di- vided into two parts: (A) Transsexuals do better in identifying the facially expressed emotions of members of their desired gender role as com- pared to members of their biological sex. (B) According to their own scores of femininity or masculinity on the BSRI, the subjects do better in identifying the facial expression of members of the respective gender.

SAMPLE

Included were 47 transsexuals who all met the diagnostic criteria for transsexualism ac- cording to ICD-10, F64.0. Their mean age was 31.9 years (SD 11.0). To test the first hypothe- sis, they were matched for age (mean 31.5; SD 10.8) with a sample of 55 non-transsexual con- trols recruited from the general population. The sex distribution was as follows: 29 (62%) were MFT and 18 (38%) were FMT (to test the third hypothesis). The sex distribution of the con- trols was the same with 62% males and 38% females.

Both, transsexuals and controls, were screened for alexithymia with the German version of the TAS (Toronto Alexithymia Scale; Kupfer et al., 2000). Although transsexuals had slightly higher scores (45.7 vs. 37.2; p < .001), it is im- portant to notice that they were still below the cut-off for alexithymia (< 50).

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The transsexual subjects were at different stages in their process of transgendering (to test the second hypothesis): 11 were at the very be- ginning of their treatment and had not yet started the RLE; 10 had started the RLE but not yet hormone treatment; 18 were in the process of the RLE and were undergoing hormone treatment, and 8 came for a follow-up after sex reassignment surgery. They all gave informed consent to the study according to the standards of ethical practice established at our university.

METHODS

All subjects of the study-group as well as the control-group accomplished the FEEL-test. In addition, the study-group completed two addi- tional tests, the BSRI and the SCL-90-R.

FEEL-Test

The FEEL-test (Facially Expressed Emotion Labeling; Kessler et al., 2002) is a com- puter-based test measuring a person’s ability to recognize facially expressed basic emotions. The stimuli which the subject has to identify consist of photographs showing facial displays of six basic emotions developed by Matsumoto and Ekman (JACFEE; Matsumoto & Ekman, 1988). The facial expressions were produced using the Facial Action Coding System (FACS; Ekman & Friesen, 1978). Participants are first confronted with neutral facial expressions of 42 Caucasian and Asian faces of males and fe- males (1:1) on a PC-screen. The same faces then are shown again for 300ms each with facial expressions of the major 6 emotions, happi- ness, anger, surprise, disgust, sadness and fear, and the participants have to identify these emo- tions by a click on the screen. With 42 items and a score of one per correct item, the FEEL score can range from 0 to 42. With a Cronbach’s coef- ficient alpha of r = .77, the FEEL-test has the highest reliability of all tests of this kind published so far.

BSRI

The BSRI was developed by Sandra Bem in 1974 to measure masculine, feminine and an- drogynous personality traits among men and

women. The BSRI consists of sixty items (20 feminine, 20 masculine and 20 non-gender re- lated items) that describe personality character- istics. Participants rate each item on a 7-point scale on how true each of these characteristics is for them. The manual published in 1978 with some updated information on the BSRI re- ported internal consistencies between .75 and .90. Test-retest reliabilities for the Femininity and Masculinity scales for the original BSRI were .82 and .94 respectively among females and .89 and .76 among males. We used the stan- dardized German version of the BSRI (Schnei- der-Düker, 1978, Schneider-Düker & Kohler, 1988) which had already been applied in a cross sectional comparison of three large groups of transsexuals at the beginning, in the midst and after completion of their process of transgender- ing, demonstrating how this process changes the self perception in regard to masculinity and femininity (Pfäfflin, 1992).

SCL-90-R

The Symptom Checklist-90-R (SCL-90-R; Derogatis, 1977) is a brief, multidimensional self-report inventory designed to screen for a broad range of psychopathological problems and symptoms. It consists of 90 items total, with 83 items representing nine subscales: somatization (12), obsessive-compulsive (10), interpersonal sensitivity (9), depression (13), anxiety (10), anger-hostility (6), phobic anxiety (7), para- noid ideation (6) and psychoticism (10). Seven additional items include disturbances in appe- tite and sleep. The rating for each item is as- sessed with 5-point Likert, ranging from “not at all distressing” (0) to “extremely distressing” (4). The authorized German version we used shows good internal consistency and validity in various subject samples (Franke, 1995). The SCL-90-R was applied to assess psychopath- ology as a possible confounding factor.

RESULTS

Hypothesis 1

With 42 items and a score of one per correct item, the FEEL score can range from 0 to 42. Transsexuals had a mean score of 33.6 com-

Kessler, Michallik, and Pfäfflin 11

pared to 35.8 in the control group (p < .01). Transsexuals were specifically less successful in the recognition of fear, disgust and anger (Table 1). Hence the first hypothesis was con- firmed: Transsexuals do recognize facially ex- pressed basic emotions less successfully than non-transsexual controls.

Hypothesis 2

To test the hypothesis that subjects having started the RLE perform better in recognizing basic emotions than those who have not yet started, we compared the FEEL score and scores per emotion between the groups at the four different stages of the process of trans- gendering. Basically there are no significant differences between subjects before and after the RLE in terms of emotion recognition scores. This is independent of hormone treatment. The only exception is the group of transsexuals who underwent SRS. They perform significantly worse than all the other subjects together (Score 35.0-29.4; p < .01). This also holds true when comparing them to each of the other groups. The second hypothesis can be rejected: The RLE itself does not influence a transsexual’s recognition of basic emotions.

Hypothesis 3

Since half of the actors displaying the basic emotions were female and the other half were

male, it could be compared how good both patient groups–MFT and FMT–were at recog- nizing the emotion in the faces of their desired sex as opposed to those in their biological sex. Both groups recognized female as well as male stimuli with no significant differences between groups and between stimuli sex. There were also no significant differences in the emotion recognition scores between MFT and FMT. The first part (A) of the third hypothesis is therefore rejected: The emotion recognition is independent of the stimuli sex and of the desired sex of the transsexual.

To test if self-descriptions of masculinity or femininity influence the emotion recognition in male and female stimuli, we compared the BSRI with the FEEL score and scores per emo- tion separately for each stimulus sex. BSRI scores did not correlate with the recognition of facially expressed basic emotions measured by the FEEL-test. Hence the second part (B) of the third hypothesis can also be rejected: Whether a subject considers himself or herself to be more feminine or masculine does not mean that he or she recognizes emotions better if they are dis- played by female or male actors respectively.

DISCUSSION

A mainly methodological problem lies in the sample size of this study. Although the total of N = 47 transsexuals can be considered an ade- quate number to compare to non-transsexual controls (hypothesis 1), the subgroup sizes to test the hypotheses within the transsexuals are somewhat limited and lead to some asymme- tries. This is especially the case for the N = 11 subjects before RLE compared to the total of N = 36 subjects after RLE (hypothesis 2) and the N = 29 of MFT compared to the N = 18 of FMT (hypothesis 3).

When reflecting the confirmation of the first hypothesis one must consider that we do not have SCL-90-R scores for the control group. Hence we do not know if the transsexuals showed more psychological problems or symp- toms of psychopathology than the control group, which could explain the poorer perfor- mance in the TS subjects in the FEEL-test. Braun and her colleagues (Braun et al., under revision) found in their study about stroke pa-

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TABLE 1. FEEL score and scores per emotion in transsexuals (TS) and non-transsexual controls (C)

Group Mean SD Significance (T-Test)

FEEL score TS C

33.6 35.8

4.8 3.8

P < .010

Fear TS C

4.3 5.3

2.2 1.7

P < .005

Happiness TS C

6.8 6.7

.5

.6 P < .507

Surprise TS C

5.9 6.0

.9 1.3

P < .783

Disgust TS C

4.9 5.6

1.7 1.5

P < .042

Sadness TS C

5.5 5.6

1.8 1.5

P < .915

Anger TS C

6.2 6.7

1.3 .8

P < .024

tients’ recognition of basic emotions that de- pression as co-morbidity did have a negative ef- fect on the FEEL performance. There are also various other studies showing the correlation between depression and less successful emotion recognition tested with different methods (e.g., Kucharska-Pietura & David, 2003; McClure et al., 2003). It is important to notice, however, that SCL-90-R scores did not correlate with FEEL performance within the transsexual group. Hence psychopathology did not affect emotion recognition in this study. The mean SCL-90-R scores for the patient group were above average compared to a norm group for this question- naire, meaning that transsexuals had more psychopathology than a standard population. What needs to be examined in further studies is, whether the less successful emotion recogni- tion is due to a transsexual-specific effect or simply a matter of increased unspecific stress or psychopathology in this sample.

The rejection of hypothesis 2 supports the as- sumption that the recognition of basic emotions is a fundamental skill as described by research- ers from the Facial Expression Program (e.g., Ekman, 1993). People develop a certain ability to decode the other’s facial expression at very early stages in their lifetime. A (perceived) changing environment–as it happens for a transsexual who starts the RLE–may not be a stimulus strong enough to change the funda- mental skill of recognizing basic emotions. The question is, of course, why the (relatively small) group of subjects after SRS performed significantly less successful in the FEEL test. It is important to notice that subjects before and after surgery are statistically equal in terms of age, response time in the FEEL test, and SCL-90-R scores. Slower reaction times or psychopathology are therefore not the cause for their less successful performance.

The assumption that the desired sex or the self-rated masculinity/femininity may cause a perceptional bias in the emotion recognition was not supported (hypothesis 3). Since we could not find any data about that topic in the lit- erature, it is difficult to view our findings in a re- search context. Reporting various meta-analy- ses, Hall found that women are superior to men in the decoding of nonverbal emotional cues (Brody & Hall, 2000). Interestingly the gender difference was relatively invariant across the

gender of the stimulus person. Since those reported differences might in part be a conse- quence of differing male and female socializa- tion, the question is to what extent a transsexual has been socialized according to his biological sex or his desired sex and gender. The finding that women decode emotions better than men, does not necessarily imply that MFT perform the same way. A possible explanation for the homogenous recognition of male and female stimuli could be the fact that all facial expres- sions were produced using the Facial Action Coding System (FACS; Ekman & Friesen, 1978). This makes the expressions uniform and may override gender specifics in the facial cues. Naturalistic pictures of emotions may have produced a certain gender bias among transsex- uals. This is, however, as of yet untested.

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