Analysis of 207 Cases from the Literature

To study some of the variables of transvestism/transsexualism I assembled all the cases from the literature described in any detail and to which I had access. These amounted to 207: 185 mates and 22 females. It was not possible to draw a distinct line between the cases of transvestism and the ones of transsexualism. But in view of the overlapping between the two conditions (e.g. Benjamin 1964a, 1966a; Roth & Ball, 1964) 1 felt justified in combining them for this purpose. Ninety-three of the 207 were ones of pure transsexualism; 36 showed a clear tendency to transsexualism-feeling of belonging to the opposite sex, abhorrence of their own genitals - but these patients made no demands for operation, and could not be classed as pure transsexuals, and the remaining 78 were cases of transvestism; these cases include occasional reports of a feeling of belonging to the opposite sex or dislike of their own genitals, but never of demands for operation. In none of the 207 was fetishism the dominant component, and they include no case with psychotic features. The amount of data the authors gave on the features studied varied, depending on what they were most interested in. In this analysis the words transvestism and transsexualism are defined according to the criteria of Benjamin (1964a, 1966a and Roth & Ball, 1964).

• Age of onset of cross-gender behavior
• Intellectual capacity
• Psychologic factors
• Familial occurence
• Physical abnormalities
• Cerebral lesions

Age of onset of cross-gender behavior

As mentioned, most authors believe that the anomaly makes its apparence at a very early age. The patients themselves usually say that they have had the feeling of belonging to the other sex ever since they could remember. It is hard to determine the age of onset from what the patients say, however, as Worden & Marsh (1955) Pointed out. One way to express the age of onset is to give the age at which the subject first dressed in clothes of the opposite sex, but this method has the disadvantage that many patients do so only sporadically, and some are prevented from doing so by various circumstances. I came to the conclusion that I could get more reliable figures for the onset of "crossgender behavior"-the time the patients first showed attitudes, interests and activities characteristic of the opposite sex-than for the onset of any other feature. This time generally coincided with the onset of the subjective feeling of belonging to the opposite sex. Information in this respect was forthcoming in 137 of the male cases and 19 of the female cases. The breakdown was as follows:

Thus the cross-gender behavior began before or during puberty in about 90 per cent of the men and women. Benjamin (1964a) noted that about 6 per cent of 108 male transsexuals began having the contrary sex feeling during puberty while about 85 per cent had had it as long as they could remember, and he found about the same figures later (1966a) in a series of 51 operated male cases. Descriptions of the first stages of the anomaly are given by several authors (e.g., Friend et al. 1954; Dorey, 1956; Schiavi and Frighi, 1956; Salfield, 1958; Schachter, 1959; Bürger-Prinz et al., 1966).
  

Intellectual capacity

Havelock Ellis (1928) pointed out that eonists were often unusually gifted. Loers & Schultz (1963) pointed out that intellectual subnormality was not uncommon among transvestites. Three of Don's (1963) four patients were of inferior intellect. But most authors believe that transvestites/transsexuals show a normal variation in intellectual capacity.
Information on the intellectual capacity was forthcoming for 73 of the men and 7 of the women in the series - sometimes the I Q's, sometimes only rough estimates like "moderately gifted", "average intellect", "normal intellect" or "highly intelligent". In the following breakdown, the ones said to be of average intelligence were put with those with an IQ between 85 and 115, the ones said to be unusually intelligent with the ones with an IQ over 115, and the ones said to be of below average intelligence with those with an IQ under 85.

Thus the patients, at least the men, were apparently distributed along the normal curve of intelligence.
  

Psychologic factors

It is naturally impossible to assess the significance of imprinting retrospectively, but I determined the incidence of three other factors thought to be of etiologic significance: parental deprivation, being dressed in the clothes of the opposite sex, and the parents having wanted a child of the opposite sex.

Sufficient data were forthcoming in 114 of the 207 cases for an analysis of the frequency of parental deprivation. The figures were as follows:

Some patients came under more than one of these headings. Taking the patients as a whole, 37 per cent of them suffered from one or more of these disadvantages.
The parents dressed the patients in the clothes of the opposite sex in 20 per cent of the cases, and had wanted a child of the opposite sex in about 9 per cent. One of these factors, called conditioning factors, was present in 31 cases or in about every fourth case. This tallies with Benjamin's (1964a, 1966a) figures of 21 per cent in 108 transsexuals, and of about 24 per cent in a series of 51 operated male cases.
  

Familial occurrence

Information on familial occurrence, positive or negative, was forthcorning in 178 cases. These contained 10 cases of familial occurrence, as follows:

Cases of particular interest from the point of view or heredity are Anchersen's (1956) and the ones found in large series by Burchard (1960, Taylor & McLachlan (1962, 1963a) and Barger-Prinz et al. (1966).
Thus there were reports of a familial occurrence in about 6 per cent of the cases. Although the figure is high, these results do not permit any conclusions on the possibility of a hereditary disposition, for cases of familial occurrence are more apt to get into print than others.
  

Physical abnormalities

To determine the frequency of deviations in physique in these cases all the cases treated with hormones had to be excluded, unless the state of their body before treatment was satisfactorily described. Similarly, all men with positive sex chromatin had to be excluded, because of the disorders in endocrine function with which this is usually combined. Finally, no cases of hormone-producing tumors or other endocrine disorder were included. This left 135 men and 21 women described in sufficient detail for a study of this variable. The data in the male cases were as follows:

The physical anomalies noted in the female cases were:

These results must be treated with caution because the different cases were naturally judged from widely divergent points of view. Some authors (e.g., Randell, 1959; Hoenig and Torr, 1964; Ball, 1966) who examined large series, and who probably judged consistently from case to case, did not observe any gross physical anomalies.
  

Cerebral lesions

One way of studying the frequency of cerebral lesions retrospectively is to study the frequency of EEG abnormality and epilepsy. The EEG's were often so summarily described in these cases from the literature, that they could only be classed as normal or abnormal. Information on the EEG was forthcoming in 42 cases from the literature as follows: