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Transvestism and
transsexualism vs. fetishism and homosexuality
Transvestism is sometimes confused with homosexuality, as pointed out by
Kinsey et al. (1953) and Armstrong (1958). Some physicians tell their patients that
their transvestism is a sign of homosexuality, and that they must accept having homosexual
relations if they are to resolve their psychologic conflicts (Kinsey et al., 1953).
Dukor (195 1) said that transvestism was the end product of passive male, or active
female, homosexuality, and Anchersen (1956) voiced much the same opinion when he said
that, from the biologic point of view, bisexuality, certain forms of homosexuality and
transvestism were different stages along a particular line of sexual deviation. Goldrach
(1963) believed that transvestism was a sign of homosexuality.
Grant (1960) said that transvestism, homosexuality and fetishism were not distinctly
separate phenornena. Flaberlandt (1950) pointed out that different forms of sexual
deviation sometimes occur together, and that sometimes one replaces the other.
Other authors believe that transvestism is clearly distinguishable from homosexuality.
One of the most prominent advocates of this opinion, Armstrong (1958), distinguished
between the two conditions in biologic men as follows: "(1) The crucial
characteristic of the homosexual is the desire for a physical sex relation with a person
of his own sex. The eonist is repelled by the physical aspect of a homosexual
relationship. (2) Homosexuals do not want to change their sex and identity. This is the
fundamental anomaly in eonism. (3) A conspicuously feminine appearance and a lifelong
preference for feminine games and activities are far more common in eonism than in
homosexuality. (4) ... preference for the feminine role in eonism is evident from early
childhood. (5) The phantasies of pregnancy and the passionate longing for a maternal role
together with the desire for castration in an attempt to achieve anatomical resemblance to
a woman are characteristic of eonism."
Other recent authors have made about the same distinction between transvestism and
homosexuality (Roth & Ball, 1964), and many have pointed out that it was necessary to
distinguish between the two (Karpman, 1947; Battig, 1952; Klotz et aL, 1955; Dorey, 1956;
Salfield, 1958; Ostenfeld 1959; Mayer-Gross, Slater & Roth, 1960).
These authors do not always agree on the definition of homosexuality, however, and some do
not say what they mean exactly by homosexuality. Only after a semantic analysis of the
type made by Hooker (1965), for example, can one work with operational definitions and
arrive at any generally applicable conclusions.
The distinction from fetishism seems to cause less difficulty, though Delay, Deniker,
Lamperi6re & Benoit (1954) said that transvestism was a special form of fetishism, in
which the fetishism was extended to involve dress as a whole.
Many say that fetishism differs from transvestism/transsexualism in that the fetish is
necessary for attaining sexual satisfaction, whereas wearing clothes of the opposite sex
has nothing to do with exciting or satisfying sexual desire (Hamburger et al., 1953;
Ostenfeld, 1959; Hoenig & Torr, 1964). Pennington (1960) noted that some transvestites
get sexual satisfaction by masturbating in front of a mirror (mirror complex). Benjamin
(1964a) concluded from a study of 200 cases that in the early stages of transvestism,
changing to the clothes of the opposite sex might be associated with pleasurable sexual
feelings, but that the feelings fade with the passage of time.
To sum up, it should be possible to make a clear distinction between homosexuality and
fetishism, on the one hand, and if not transvestism, at least transsexualism, on the
other.
Deviant sexual
behavior and gender role
Attempts to distinguish between different types of deviant sexual behavior
have led to the term "gender role" (Hampson & Hampson, 1961; Hampson, 1963,
1964). According to Hampson (1964) gender role means "all those aspects of a person's
behaviour and attitudes which serve to disclose the person as having the status of boy or
man, girl or woman. It includes, but is not restricted to sexuality in the sense of
eroticism." Gender role, or "psychologic sex" as the Hampsons also call it,
is one of the several components of sex. According to Money, Hampson & Hampson, (1957)
and Hampson & Hampson (1961) these components are: (1) chromosomal sex, (2) gonadal
sex, (3) internal anatomic sex, (4) external anatomic sex, (5) hormonal sex, (6) sex of
assignment and rearing, and (7) gender role, or psychosexual identification.
Armstrong (1964) stated that an intersex state was present whenever chromosomal sex,
gonadal sex, apparent sex (external genitals and body build) did not agree in full with
psychologic sex, and thus widened the concept of intersex to include deviations in
psychosexual identification. When one considers psychologic sex to be a variable of sex,
one does not need nonspecific, moralizing terms like perversion for classifying deviant
sexual behavior: when a subject behaves like someone of the opposite sex and feels like
someone of the opposite sex, it is a case of inversion in gender role. Thus Hampson (1964)
classified deviant sexual behavior according to whether or not it was associated with
gender role inversion, -fetishism, exhibitionism and impotence being associated with a
normal gender role, and transvestism being a form of gender role inversion.
Stoller (1964a, b, c, 1965) formulated the concept of "core gender identity" for
the feeling of "I am male" or "I am female" as distinguished from
"gender role" for a masculine or feminine way of behaving. "Core gender
identity" seems to be the better one of these terms to use when describing the
transsexuals' feeling of the sex to which they belong.
Types of transvestism
It is important to make clear from the outset that transvestism may be a
characteristic of several different conditions (Stilrup, 1956; Roth & Ball, 1964).
Both Stfirup (1956) and Armstrong (1958) pointed out that cross-dressing was common among
homosexuals, and StOrup (1956) and Fossel & Teirich (1951) pointed out that criminals
sometimes used it to conceal their identity. The transvestism in these cases is
symptomatic, and should be distinguished from real transvestism in which there are no such
secondary motives for the cross-dressing.
Some authors, the early ones in particular, have classified transvestism. according to the
object or strength of the sexual drive. Thus Hirschfeld (1938) divided transvestites into
heterosexual, homosexual, bisexual, automonosexual, and asexual transvestites, Binder
(1933) into heterosexual, asexual, bisexual and homosexual transvestites, and Battig
(1952) into heterosexual, homosexual, bisexual and autosexual transvestites; Dukor (1951)
used a slight modification of Bdttig's classification. Naecke (Bing & Sch6nberg, 1922)
divided transvestites according to how often they cross-dressed, into temporary,
intermittent and permanent transvestites. Hirschfeld (1938) divided transvestites on the
same basis into partial and complete, and Kinsey et al. (1953) did the same.
Pettow (1912) used a more descriptive method of classification, dividing the subjects
into: men who dressed like women, women who dressed like men, and adults who dressed like
children.
Roth & Ball (1964) divided transvestism into three varieties: (1) symptomatic, (2)
simple, in which the subjects confine themselves to cross-dressing and do not want to be
operated on, and (3) transsexualism. Benjamin (1954) distinguished between three types of
genuine transvestism: (1) chiefly psychogenic, (2) intermediate, and (3) psychosomatic,
the latter characterized by an intense desire to change anatomic sex. Later (1966a) he
constructed a "sex orientation scale" covering six types of "sex and gender
role disorientation and indecision" ranging from pseudotransvestites to transsexuals.
Stilrup (1956) classified transvestites into: (1) antisocial subjects wearing the clothes
of the opposite sex to conceal their identity, (2) transvestites with a tendency to
fetishism, or vice versa, (3) homosexuals with secondary reasons for cross-dressing, (4)
asthenic adolescent transvestites, who sometimes recover completely when they mature, and
(5) genuine transvestites or conists.
Whether or not transvestism is a nosologic entity is a subject of debate. St6rup (1956)
says that it is not, and regards transvestism only as a symptom. Transsexualism seems to
be easier to delimit, and Ostenfeld (1959), Burchard. (1961), and Barker (1966) stated
that it was probably an independent syndrome.
Transvestism and psychosis
Lukianowicz (1959b) reported a case of transvestism combined with
psychosis, and collected 15 other cases from the literature. Later (1962, 1965) he
described 3 more cases, and Reimer (1965) described 2 cases. Lukianowicz suggested three
causes for a combination of the two conditions: (1) An acute psychosis might cause latent
transvestism to flare up, (2) the combination might be due to pure coincidence, and (3)
transvestism might develop during a chronic psychosis without there being any clear causal
connection between the two. Cases of the first type have been described by Liebman (1944),
Lukianowicz (1962) and Reimer (1965). An example of the second type has been described by
Fortineau, Vercier, Durand and Vidart (1939), and the same authors described a case of the
third type.
Only a few cases of this combination are so clearly described that it is possible to
classify the psychosis; examples are those of Lukianowicz (1959b, 1962, 1965) and Reimer
(1965). It seems however, that both schizophrenic and schizophreniform, and
manic-depressive psychoses and confusional states are represented among the cases.
Pauly (1965) found, on analyzing 100 transsexuals from the literature that 19 per cent
were overtly psychotic "or schizophrenic."
Gittleson & Levine (1966) noted that genital hallucinosis and a delusion of sexual
transformation were significantly more common among schizophrenic than non-schizophrenic
but otherwise mentally diseased subjects.
Baastrup (1966) considered that the transsexual's feeling of belonging to the other sex
had the character of a delusion and that they could therefore be classified as paranoiacs.
Strength of
sexual drive and sex orientation
Many have noted that transvestites often have a weak sexual drive (e.g.
Delay et al., 1956; Birker & Klages, 1961; Roth & Ball, 1964; Pauly, 1965).
Gutheil (1954) pointed out that transvestites often did not begin having sexual relations
until late, and Burchard (1961) noted that advanced cases were often characterized by
"Anorgasmie" -even absence of masturbation.
As to the sex object choice, Hirschfeld (1938) stated that 35 per cent of his patients
were heterosexual, 35 per cent homosexual, 15 bisexual, and the remaining 15 per cent
chiefly automonosexual. Pauly (1965) found in a retrospective study that 39 per cent of
100 transsexual men had overt sexual relations with other men. Roth & Ball (1964)
found that 52.9 per cent of 17 transsexual men were heterosexually active, and 11.8 per
cent homosexually active. These authors pointed out, like Randell (1959), that nearly all
transsexual women were homosexually inclined. Hamburger (1953) found from letters he
received from 75 male and 77 female transvestites after wide publication of a case of
transvestism, that 39 per cent of the men were heterosexual, 40 per cent homosexual (19
per cent having only homosexual desires, and 21 per cent homosexual attachments and
relations), and 21 per cent hisexual, autosexual or asexual; and that all the women were
homosexual, 18 per cent having homosexual desires, and 82 per cent homosexual attachments
and relations.
Randell (1959), reporting on an apparently mixed group of transvestites and transsexuals,
noted that homosexuality was more common among the transsexuals, and that it was more
common in the women than in the men. Others have noted the same (e.g., Prince, 1957;
Benjamin, 1964a and b). An interesting observation is that transvestites who have
homosexual relations, transsexuals in particular, do not regard these relations as
homosexual in the conventional meaning. Because these persons identify themselves so
strongly with the opposite sex, they regard sexual relations with persons of their own
anatomic sex as heterosexual, not homosexual as others do. Nor do they want partners with
homosexual leanings; they want their partners to be heterosexually oriented-in fact, some
are very critical of homosexuality (e.g. Kissel, Hartemann & Laxenaire, 1961; Sendrail
& Gleizes, 1961; Benjamin, 1964a, b; Pauly, 1965).
As mentioned, the definition of homosexuality presents considerable semantic problems.
Randell (1959) classified homosexual attitudes according to Kinsey's scale for male sexual
behavior (Kinsey et al., 1948), and it is clear what he means by homosexuality. It
is harder to understand what others mean, and it is well to remember this when studying
their figures. As Hooker (1965) summed up: "there is no apparent correspondence
between a conscious sense of gender identity and a preferred or predominant role in sexual
activity".
To sum up, it would appear that the tendency to homosexual interests and relations
increases with the intensity of the transsexual phenomenon and that the females are more
often homosexual than males. Otherwise, many males are heterosexually inclined, and not
seldom marry (e.g., Randell, 1959). Bfirger-Prinz and Weigel (1940) pointed out that the
men vary between passive and active sexuality, without showing any particular deviation
from the normal pattern.
Stages
in development of transvestism/transsexualism
The literature contains exhaustive descriptions of the mental
characteristics associated with transvestism/transsexualism (e.g., Ellis, 1928; Hamburger et
al., 1953; Benjamin, 1954, 1964a, b, c, 1966a; Roth & Ball, 1964).
Most authors seem to agree that transvestism usually makes its appearance early in life.
The first signs often appear as early as the age of five, ("Thompson", 1951;
Nathan, 1965). Taylor & McLachlan (1962) said that most of their 10 cases began before
the age of 12. To begin with, the subjects show a strong tendency to adopt the attitudes
characteristic of the opposite sex and to behave in the manner considered appropriate for
the other sex. The cross-dressing usually starts later (Robbe & Girard, 1959; Roth
& Ball, 1964), around the age of 5 to 8 (Roth & Ball, 1964).
Only rare cases of a later debut-during adolescence or later-are published (e.g., Fessler,
1933; F6rster, 1957).
The feeling of belonging to the other sex usually becomes more intense around the time of
adolescence, and from then on the deviation seems to split in two. Either the subjects
remain content to dress in the clothes of the opposite sex, consistently or sporadically,
and are not particularly troubled by the external signs of sex on their bodies; these
cases are not especially dramatic, and apart from the dressing anomaly, the subjects do
not behave peculiarly (Lukianowicz, 1959a); they are often able to adjust and canalize
their transvestism so as not to come into conflict with the norms of society. The other
subjects, the transsexuals, get worse after adolescence. They grow more and more repelled
by their external sex characteristics. They become more and more convinced that nature has
blundered and that they have the soul of one sex and the body of the other (e.g., Alby,
1959; Hofer, 1961; Benjamin, 1964a). They persist more and more in their demands for
medical measures to "change" their sex, whether it be hormones or plastic
surgery, or both-demands that are seldom prompted by sexual motives (Brdutigam, 1958).
Some do what they can to change their appearance themselves: the men pluck their eyebrows
and take away their facial hair, they shave their arms and legs, and they trim their pubic
hair to make it look feminine. Others try to make their bodies look like a woman's by
injecting paraffin into their breasts and by other means (Bobon, Gomez, Gernay, Goffloul
& Liegeois, 1965).
In occasional cases the anomaly comes and goes, the desire to change clothes or to be
identified with the opposite sex waxing and waning (Pennington, 1960; Bdrger-Prinz et al.,
1966). But in most cases the desire to pass over into the opposite sex grows steadily
worse and worse, and the victims often grow more and more suspicious of their fellow-men
whom they feel make no effort to understand or help them (Delay et al., 1954). The end
result is often a conviction that one is being persecuted. Many transsexuals do not ask
for help until they get into trouble (Gutheil, 1954) or until they break down under the
pressure, material or mental, to which they are subjected. Another specific
characteristic: they want one kind of treatment only-"a change of sex"; they
never want to be "cured" of their "aberration" (e.g., Grotjahn, 1948;
Birker & Klages, 1961; Nedoma & Mellan, 1966).
As time goes on, the transsexualism becomes associated with other mental peculiarities.
Sometimes the subjects get the feeling that their bodies actually have the characteristics
of the opposite sex (Allen, 1962) their genitals feel changed; the men begin to feel that
their breasts are swelling, their skin is growing more like that of a woman and their hair
is becoming distributed in another manner. Some men begin to think they have ovaries
(Alby, 1959) or other female characteristics, and some are convinced that they menstruate
(Overzier, 1955; Allen, 1962; Bdrger-Prinz et al., 1966), or regard their
ejaculations as leukorrhea (Alby, 1959). Some men have phantasies of being pregnant and
some dress to look as if they were pregnant (Hirschfeld, 1938).
Persons who feel that their anatomy is changing or who use drastic measures to change
their appearance to that of the other sex are not seldom on the brink of disintegration in
personality, and attempts to make transsexuals change their ideas of belonging to the
opposite sex, by psychotherapy or other measures, sometimes result in a real psychosis
(Don, 1963; Pauly, 1965).
Typical of transsexualism are the exaggerated idea of belonging to the other sex, the
desire to become a perfect specimen of the other sex, repulsion at the sight of one's own
genitals, and the feeling that others are against one (Delay et al., 1956). To
these traits Worden & Marsh (1955) added: a memory disorder-the subjects being only
able to remember events bearing out that they identified themselves with the opposite sex
from the very beginning-and the wrong feeling their genitals give, which makes having them
removed like being rid of a cancer. Others have drawn attention to the selective form of
recall (Plichet, 1955; Robbe & Girard, 1959).
Sometimes the desire to change sex reaches the proportions of an obsession (Pettow, 1912;
Alby, 1959; Randell, 1959; Israel & Geissmann, 1960). When physicians and surgeons
refuse to help these patients to get the change they want, their persecution complex grows
even more intense, and many then mutilate themselves to get the appearance they want, or
become depressed and suicidal.
Attempts at autocastration or to remove one's penis have been reported in several
different kinds of mental disorder, though rarely, and they are not specific of any
particular disorder (Solms, 1952; Blacker & Wong, 1963). There is a large risk of this
in transsexualism, however (Delay et al., 1956; Fogh-Andersen, 1956). Grotjahn
(1948) described a transsexual who tried to castrate himself three times, and once
succeeded in enucleating a testicle, and several other cases of autocastration and
amputation of the penis are reported (Wyrsch, 1944; Tolentino, 1957; Benjamin 1966a).
Pauly (1965) analyzing 100 male transsexuals from the literature, found that 18 of them
had tried or succeeded in amputating offending parts of their body.
Depressive reactions and attempts at suicide are other serious complications sometimes
occurring in transsexualism (e.g., Hirschfeld, 1938; Delay et al., 1956;
Fogh-Andersen, 1956; Randell, 1959; Bfirger-Prinz et al., 1966). Thirty-five per
cent of Pauly's cases from the literature had suicidal thoughts, and 17 per cent had
attempted suicide.
Personality
Most authors proceed extremely cautiously when they enter into a
discussion on the basic personality of these subjects.
Roth & Ball (1964) found that obsessional and dysthymic features occurred
significantly more often in transsexual men than in a matched control group of
homosexuals. They noted also that their patients were shy and reserved, and said that the
majority of them were "sensitive, conscientious, determined and foresightful."
Havelock Ellis (1928) also pointed out the sensitive and refined nature of the subjects,
and the obsessional tendency has often been noted (Pettow, 1912; Masson, 1939; Aubert,
1947; Alby, 1959; Randell, 1959; Israel & Geissmann, 1960). Gutheil (1954) maintained
that the personality must contain elements of sado-masochism, narcissism, scotophilia,
exhibitionism, and fetishism in order for transvestism to develop, and Delay et al.
(1954) expressed the same opinion.
Frequency
Reliable data are lacking on the prevalence or incidence of transvestism
transsexualism. For one reason, probably only the subjects at the extreme end of this
scale-the ones under the greatest strain-consult a physician and get into the statistics.
There will always be a large number who can adjust themselves- to their surroundings, and
are never uncovered. When an unusually large number of cases turn up within a short
period, it is often because of the publicity given a case in which a person has had his or
her sex "changed" by a surgeon.
Because of this, it is only possible to guess at the frequency of the anomaly, and widely
divergent opinions on tile rate have been expressed, from the opinion that it is the next
most common sexual deviation after homosexuality (Bing & Sclibriberg, 1922; Armstrong,
1958), that it is a "quite common perversion" (Wilson, 1948), that it is an
uncommon anomaly though perhaps more frequent than commonly supposed (Hamburger et al.,
1953), down to the opinion that it is rare (Birker & Klages, 1961). Turtle (1963)
reckoned that it occurred in between 3,000 and 15,000 of a population of about 50 million,
which corresponds to a prevalence between I per 17,000 and I per 3,300.
Anchersen (1965) found 3 transsexual men among 2,000 males admitted during three years to
Ullevdl's Hospital in Norway, compared with 28 homosexuals, 12 bisexuals, and I
exhibitionist. In an earlier article (1956) Anchersen said he knew of 8 transvestites
among Norways's about 3,300,000 inhabitants. Hamburger et al. (1953) said that they
knew of 5 transvestites (probably eonists) in a population ' of about 4 million. Bowman
& Engle (1957) reported that "fewer than a dozen cases" were admitted during
15 years to the Langley Porter Clinic but did not say how many other patients were
admitted during this period.
Benjamin (1964c) said that there were probably several thousand transsexuals in the
Western world, and described 125 cases he had collected during the course of 13 years.
Pauly (1966) estimated that I out of every 100,000 men and I out of every 400,000 females
was a transsexual.
Sex ratio
The early literature dealt mainly with transvestism/transsexualism in
males. The psych oanalytical explanation for transvestism -a symbolic form of denial of
castration-fear through creation of a phallic woman -excludes the possibility of the
anomaly in women (Lukianowicz, 1959a). It is now realized, however, that the anomaly
occurs in both sexes.
Kinsey et al. (1953) said that the male-female sex ratio was 100:2-6. Twenty-one of
Randell's (1959) 30 transsexuals were men and 9 women, and 37 of his combined group of
transvestites and transsexuals were men and 13 women, giving M/F ratios between about
2.3:1 and 2.8:1.
After a widely publicized case in Denmark, Hamburger (1953) got letters from 465 persons
from all over the world asking him to help them change their sex; 357 of them were men and
108 women. Hamburger classified only 115 of the 357 men as transvestites, and only 62 of
these as what he called genuine transvestites. He was cautious in his deductions, saying
only that the desire to change sex could be found among both men and women, but much more
often among men.
The figures for the largest series of transsexuals published are: 152 men vs. 20 women, or
a M/F ratio of about 8:1 (Benjamin, 1966a).
The greater proportion of men has been explained in different ways. Lukianowicz (1959a)
pointed out that, in the Western world, men dressing as women are apt to get arrested, but
that women dressing as men are tolerated more, both by law and society. Furthermore, it is
much easier for women to get work which allows them to dress in masculine clothing -for
instance, on buses or in machine-repair shops -than vice versa. This makes it easier for
female transsexuals to adjust themselves to their anomaly than it is for men, who in the
end are often forced to seek medical help. The result is that physicians come into contact
with many more male than female cases. Kinsey et al. (1953) concluded that the sex
difference might be due to men being more easily conditioned to psychologic
stimuli-"There are few phenomena which more strikingly illustrate the force of
psychological conditioning."
One of the most intriguing problems in sex research is why men are more apt to have sexual
anomalies than women, no matter what the culture (Roth & Ball, 1964).
Cultural
differences in attitude to sex anomalies
As mentioned, the Western world looks more kindly on a woman who dresses
slightly mannishly than it does on a man who dresses like a woman.
Other cultures vary greatly in their attitude to cross-dressing. In some, among the
Samoans, for example, transvestism is unknown (Lukianowicz, 1959a). In others it is
common, and even encouraged (Mohave Indians and Plain Indians). Some tribes not only
accept transvestism, but transvestites rank high in the social scale, and play an
important part, for example, in religious rites. Margaret Mead (e.g., 1961) and others
have given lengthy descriptions of the attitudes of different cultures to anomalies of
this kind.
Ford and Beach (1952) described the attitudes of other cultures. Examining 79 primitive
peoples, they found that 49 regarded homosexuality as normal and quite acceptable
socially. The commonest form of institutionalized homosexuality is that of the
"berdache" or transvestite. This is most often a man "who dresses like a
woman, performs women's tasks and adopts some aspects of the feminine role in sexual
behaviour with male partners."
Psychoanalytic explanations
Most of the psychoanalytic theories on transvestism/transsexualism are
based on the teachings of Freud (1904, 1927, 1931, 1933), and trace it mainly to efforts
to counteract castration anxiety. Some authors, especially Fenichel (1930, 1945, 1949),
have extended this theory; Fenichel contended that the male transvesite is a combination
of a homosexual, who identifies himself with his mother, and a fetishist who will not
relinquish the belief that women have a penis: he identifies himself with the phallic
woman, and believes in her existence. Similar theories have been propounded by, among
others, Shanket and Carr (1956) and Thomd (1957) and modifications on the same theme have
been published by others (Hora, 1953; Friend, Schiddel, Klein & Dunaeff, 1954; Grant,
1960).
Segal (1965) maintained that, in addition to a castration complex, the anomaly stemmed
from a separation complex-the fear of being separated from one's mother or father figure.
Schw6bel (1960) believed that the undifferentiated and undeveloped components
characterizing the personality of these patients were important factors. Tolentino (1957)
said that a faulty ego-feeling helped to cause transvestism, and that the conception
transsexual men had of their bodies made them want to have their physical appearance
changed; that as a rule this mechanism remained unconscious, but that it sometimes broke
through into the conscious and made them want to castrate themselves.
As Roth & Ball (1964) pointed out, it is hard to understand how transsexualism could
be derived from castration anxiety; these people are not afraid of castration, they seek
it. Greenberg, Rosenwald & Nielson (1960) believed that the desire for castratibn was
a "defence against homicide directed especially toward the mother figure or mother
surrogates."
Because there are so many different schools of psychoanalysis, and because psychoanalytic
explanations for transvestism/transsexualism. have so far been based on only a few cases,
it is hard to judge how plausible they are. Furthermore psychoanalysts generally do not
differ between transvestism. and transsexualism, and many do not distinguish them clearly
from fetishism and other sexual deviations.
Other psychologic explanations
Many stress the importance of an unhappy childhood, preventing normal
psychosexual development. Psychologic conditioning and faulty identification are terms
often brought up in this connection (LukianoWIC7, 1959a). Some of the main explanations
based on this reasoning are tile following:
Parental rejection. The anomaly is due to the parents having
wanted a child of the opposite sex instead; rejected by its parents, the child becomes
unsure of itself, and becomes prematurely occupied with the idea of masculinity-femininity
(e.g., Barahal, 1953; Gutheil, 1954; Alby, 1959), and may regard its genitals as the
reason for its failure (Alby, 1959).
The child dressed in the clothes of the opposite sex.
According to Lukianowicz (1959a), practically every male transvestite has been dressed in
girls' clothes at least off and on till the age of 3 or 4, and this affects the boy's
conception of, and identification with, his own sex.
Close visual contact ivith persons of opposite sex. Some
adults go about naked a great deal in their hornes, often in front of young relatives for
exhibitionistic reasons. This is a common cause of faulty sex identification, according to
some authors (Karpman, 1947; Friend et al., 1953; Lewis, 1963), and according to others it
is often the explanation for other kinds of sex deviation as well (Johnson & Robinson,
1957).
Reversal in parental role. Several blame a reversal in
parental role (e.g., Deutsch, 1954). According to this theory the male transvestite has a
domineering, aggressive, over-protective mother and an inadequate father figure, either
because of a weak, colorless father, or because of the family lacking a father. Tiller
(1958) said that the lack of a father should cause a compensatory, over-masculine
attitude, and so militate against difficulty in identification and a feeling of inadequate
masculinity.
Other authors blarning a disorder in sexual identification - either an enhanced
identification with the parent of the opposite sex, or inadequate identification with the
parent of the same sex - are Taylor & McLachlan (1963a, 1964) and Prince (1957). Ball
(1966) pointed out that the parents often had an abnormal personality.
Imprinting. Money and Hampson & Hampson believed that the
sexual anomaly could be traced to imprinting (e.g., Money et al., 1957; Hampson &
Hampson, 1961; Money, 1961a, b, 1963). Studying hermaphroditic children, they concluded
that the establishment of gender role was analogous to the imprinting phenomenon seen in
animals. They noted in a study of about 100 hermaphrodites that the gender role and sexual
identification nearly always depended on the way the child was reared, though it might
have been assigned a sex contrary to its chromosomal, gonadal or hormonal sex. If the
child was assigned another sex after about the age of 18 months, it might lead to serious
mental conflicts, according to these authors. Hampson later (1965) confirmed these
observations with a larger series.
Studying 11 pre-adolescent boys with an effeminate personality, Green & Money (1961)
concluded that no aspect of gender role behavior was established at birth-that it was
established after birth by different external stimuli, that just as a child is born with
the ability to learn a language, but the actual language it speaks depends on environment,
its psychosexual differentiation also depends on external factors. Money (1965), like
Hampson & Hampson (1961) and Hampson (1965), contended that children were
psychosexually neutral at birth. Ellis (1945) and Vblkel (1963) also pointed out the
importance of environmental factors.
Some authors do not agree on the importance of imprinting and disagree particularly with
the idea that a surgical "change of sex" would be harmful after the age of 18
months. Dewhurst & Gordon (1963) reported 20 cases in which an operation after this
age had surprisingly successful effects on the patients. Others have reported the same
(Norris & Keettel, 1962; Berg, Nixon & MacMahon, 1963; Brown & Fryer, 1964;
Armstrong 1966).
Change in, or inappropriate body image. That an inappropriate body image at
least contributes to the development of transvestism /transsexualism has been suggested by
several, including Bowman & Engel (1957). Delay et al. (1956) also pointed out
that a change in body image, for instance, through endocrine disorder, might tend to
change psychosexual behavior, partly through the subjects' own reaction to the change in
their anatomy and partly through the reactions of others.Those reasoning on psychoanalytic
lines also consider that an inappropriate body image might help to cause the anomaly
(e.g., Tolentino, 1957 and Lewis, 1963).
It is hard to determine the part played by body image on the anomaly. Schonfeld (1962),
studying 284 men with gynecomastia when they were adolescent was unable to establish that
this had any effect on their sexual life but he pointed out that gynecomastia gave the
adolescent boy more trouble than it did the adult man. On the other hand, there is no
doubt that a normally developing body favors normal psychosexual maturation and that
deviations from the normal in anatomy, especially during adolescence, increase the
risk of mental trauma, more so in boys than in girls (Money, 1961 a; Hampson,
1965).
Organic explanations
Genetic factors. Goldschmidt's (1931) observation of intersex
states in the gipsy moth (Lymantia dispar) has led to the theory that transsexualism is an
intersex state. Binder (1933) and after him Hamburger et al. (1953) looked upon this
anomaly as intersex "of the highest degree". Dukor (1951) also mentioned the
possibility of "constitutional intersexuality," and a similar opinion was
expressed by Lammers (1959). Melicow and Uson (1964) suggested that the anomaly might be
due to a chromosomal disorder in a postulated psychosexually discriminating gene.
Barr & Bertram's (1949) discovery of sex chromatin has led to many studies of the
chromosomal sex in transvestites/transsexuals. Nearly all these studies have revealed
correspondence between the sex chromatim pattern and anatomic sex (e.g., Barr & Hobbs,
1954; Bleuler & Wiedemann, 1956; Overzier, 1958b; Burchard, 1963; Benjamin, 1964c;
Ball 1966), and this has been borne out by determinations of the karyotype. Some authors,
however, have found male transvestites/transsexuals with positive sex chromatin (Bishop,
1958; Davidson, 1958; Overzier, 1958a; Walter & Brdutigam, 1958; Dowling & Knox,
1963; Karl & Meyer, 1964; Money & Pollitt, 1964; Miller & Caplan, 1965;
Davidson, 1966). Money & Pollitt (1964) did not find a statistically significant
correlation between positive sex chromatin and transvestism. in men. Robinson (1966)
mentioned a case of positive sex chromatin in a man who felt himself to be a woman, but it
is not sure that this man was a transsexual, and the possibility of a complicated
psychotic reaction in this case cannot be excluded. None of Bambert's (1966) 75 males with
positive sex chromatin showed any signs of transvestism or transsexualism. Nor did
Lindsten (1963) or Hampson (1965) find any in 49 and 13 adult Turner subjects.
Havelock Ellis (1928) contended that the anomaly was sometimes inherited, but most later
authors believe that it never is. There are occasional reports, however, of transvestism
among near relatives of the patient or other sexual aberrations in the family (e.g.,
Lammers, 1959; Randell, 1959; Taylor & McLachlan, 1962, 1963a; Roth & Ball, 1964).
Anchersen's (1956) observation of transvestism in monozygotic twins is particularly
interesting.
Slater (1962) found that the birth order and maternal age in 36 cases of transvestism did
not differ significantly from the expected figures.
In the opinion of some authors, the physical abnormalities seen in
transvestism/transsexualism point to a constitutional origin, for example, the scanty
beard, high-pitched voice, testicular hypoplasia and feminine build in the males and the
virilism and poorly developed breasts in the females. Benjamin (1966a) reported that 40
per cent of transsexual men were underdeveloped sexually (sexual drive included), and many
had the female type of pelvis and hair. Vague (1956) and Decourt & Guinet (1962) drew
attention to the feminine build of male transsexuals.
It is hard to evaluate the significance of the observations reported by these
authors, for they used different systems for classifying characteristics and they often
only describe their patients in vague terms.
Hormones. The literature contains one case of a combination of
transsexualism and an estrogen-producing tumor of the adrenal glands in which the
transsexualism diminished after the tumor was removed (Routier, Paget, Ernst, Langeron,
Wiart, Duthoit & Cousin, 1964). Bleuler (1954) reported a case of an
androgen-producing testicular tumor combined with transvestism. Schwabe, Solomon, Stoller
& Bumham (1962) reported a case of postadolescent fernininization (but a feminine
personality already at the age of 4) combined with a male genotype and phenotype, but with
atrophic testes, in which the subject grew less feminine after orchiectomy. Sendrail &
Gleizes (1961) reported a case of a hyperandrogenic evolution syndrome (hypertrichosis,
amenorrhea, enlargement of clitoris) combined with transsexualism. Stoller, Garfinkel
& Rosen (1960) reported a case of a chromosomally normal man with a feminine build
except for a normally sized penis and male internal characteristics, who produced an
excess amount of estrogens for no discoverable reason, and showed a feminine psychosexual
orientation though he had been brought up as a boy.
Green (1958) described a case of transvestism developing suddenly in connection with the
development of liver cirrhosis, in which the anomaly disappeared after testosterone
treatment, and he concluded that the anomaly might have been caused by the inability of
the liver to conjugate circulating estrogens, with the result that they reached an
abnormally high concentration. Lief, Dingman & Bishop (1962) described a case of
cyclic variation between a feeling of masculinity and femininity combined with variations
in the content of 17-ketosteroids in the urine. BfirgerPrinz et al. (1966) described a man
with idiopathic eunuchoidism, in which hormone treatment reduced the eunuchoid features,
heightened the libido, and caused disappearance of the transsexualism.
Young, Goy & Phoenix (e.g., 1965) concluded after a number of animal experiments that
hormonal factors must be taken into account when studying psychosexual attitudes, and
Robbe & Girard (1959) stated that neuroendocrinologic factors might play a much
larger part than previously recognized. Authors who have made systematic analyses
of the hormone balance in large series of patients, however, have generally not been able
to detect any deviations from normal (Overzier, 1955; Randell, 1959; Don, 1963; Hoenig
& Torr, 1964).
Cerebral lesion. Relatively little interest has been shown in
the cerebral lesions occurring in transvestism/transsexualism, though cases of this
combination were described as far back as 1869 by Westphal. KrafftEbing (1892) pointed out
that the anomaly might be derived from "anomalies in the cerebral organization".
Pennington (1960) suggested that a cerebral disorder of biochemical nature might be at
fault. Epstein (1960, 1961) made the same suggestion.
Cases of epilepsy among persons with this psychosexual anomaly provide more concrete
evidence of the possibility of a cerebral lesion (Petritzer & Foster, 1955; Davies
& Morgenstern, 1960; Taylor & McLachlan, 1962; Hunter, Logue & McMenemy,
1963).
Cases with abnormal EEG's have been described (e.g., Davies & Morgenstern, 1960;
Epstein; Don, 1963; Hunter et al., 1963). In some of these cases, the disorders
seem to be mainly of temporal origin (Davies & Morgenstern, 1960; Epstein, 1961;
Hunter et al., 1963), which is interesting in view of the relationship between
injury to the temporal lobes and endocrine disorders (e.g., Lundberg, 1964).
In 1965 1 published a short review of the evidence in favor of origin from a cerebral
lesion collected up to then in transvestism/transsexualism, as well as in other forms of
sexual deviation. The same year de Martis & Ravasini (1965) published a similar study.
It has been observed that toxic conditions affecting cerebral function cause episodes of
transvestism or transsexualism, or accentuate already existing transsexualism (Delay et
al., 1954; Connell; 1958, Ball, 1966), and it may be that head injuries can change a
previously normal psychosexual pattern into transvestism/transsexualism (Wdlinder, 1965).
Cases of men have also been described in which transvestism and the feeling of being a
woman developed suddenly late in life, in conjunction with the onset of senile changes
such as cerebral arteriosclerosis (e.g., Fbrster, 1957).
Up to now, no one has published a series of cases of transvestism/ transsexualism in which
the subjects have all been examined in consistent fashion for disorders in cerebral
functioning, and so no definite conclusion can be drawn in this respect.
To sum up, more and more importance has been attached to the part played by organic
factors, partly because of the results of animal experiments (Harris, 1963; Gagnon,
1965; Barton & Ware, 1966). But opinions still diverge widely. For example,
Housden (1965) contended after an analysis of 75 cases from the literature, that he could
not find any evidence that they were important, while other reports, as mentioned, point
to an organic origin, at least in some cases.
Multifactorial theories
Some authors, especially those with first-hand knowledge of a large
number of cases, are inclined to believe that the anomaly is due to a combination of
factors. Benjamin (1954, 1964a, 1966a) for example, stated that it was probably due to a
combination of constitutional, psychological and hormonal causes, and several others say
much the same (e.g., Aubert, 1947; Delay et al., 1956; Overzier, 1958a; Burchard, 1961;
Roth & Ball, 1964; Bürger-Prinz et al., 1966).
Response to treatment
Psychoanalysis and other'16rms qf psychotherapy. Authors with any
experience of transvestism or transsexualism seem to be agreed that there is no way of
getting at the underlying cause, especially in the case of transsexualism (Burchard, 1961;
Benjamin, 1964a, b; 1966a; Anchersen, 1965; Barker, 1966). Benjamin (1964a) said that in
principle one should try to make the subjects adjust their minds to their bodies, for
example through psychotherapy, but that this was usually impossible because the patients
refused to co-operate -they do not want to change their attitude to the sex to which they
belong. Gutheil (1954) said that even though the patients benefited little from
psychotherapy, it did not mean that one could not explain transvestism/transsexualism on
psychoanalytic grounds-that one should still do all one could to make the patients
understand the mechanisms leading to their anomaly.
Most patients who have improved under psychotherapeutic treatment seem to have been
transvestites. Some think that this is the best form of treatment (Ostow, 1953; Thomd,
1957; Tolentino, 1957). Many say that psychotherapy or analysis is the only way to reduce
the social pressure and facilitate adjustment to society (e.g., Peabody, Rowe & Wall,
1953; Israel & Geissmann, 1960), and some have reported good results with this form of
treatment (Deutsch, 1954, Schachter, 1959; Schw6bel, 1960; Philippopoulos, 1964). Don
(1963) said that psychotherapy was the only kind of treatment for transsexualism, that
nothing else helped. Israel & Geissmann (1960) said the same, and that the physician
should not give way to the patients' demand for surgical change in their anatomy.
Behavior therapy. Behavior therapy is based on Pavlov's
classical theory of conditioning. With it, an attempt is made to create an aversion to
cross-dressing by associating it with something unpleasant. First apomorphine and emetine
were used for the purpose (Davies & Morgenstem, 1960; Barker, Thorpe, Blakemore, Lavin
& Conway, 1961; Glynn & Harper, 1961; Lavin, Thorpe, Barker, Blakemore &
Conway, 1961), later faradic stimulation (Blakernore, Thorpe, Barker, Conway & Lavin,
1963; Barker, 1965). The last named authors maintain that behavior therapy is the most
common method used for treating sexual aberrations like transvestism and fetishism. But to
get good results with this method the patients must have a suitable personality and strong
motivation, be willing to cooperate, and be well equipped intellectually (Barker, 1965).
The results obtained with this method have been encouraging, both in the long and short
run. Exceptions are the cases of Davies & Morgenstern (1960). It must be remembered,
however, that most of the cases responding well to this treatment have been ones of
transvestism without a strong tendency to transsexualism.
Administration of contrary sex hormones. Treatment with contrary
sex hormones has been used mainly in cases of male transsexualism, and then often as a
preliminary to surgical treatment (e.g., Hamburger et al., 1953). Jones (1960)
maintained that, while some transvestites benefit from this form of treatment,
transsexuals respond very little to it.
As Benjamin (1964b) pointed out, giving estrogens to male transsexuals has the advantage
that it eventually leads to chemical castration. It calms the patients because it lessens
their libido, and they welcome its feminizing effect. Treatment with homologous hormones,
on the other hand, is only apt to make them more restless and anxious.
Surgical measures. Some recommend castration or placing the testes somewhere
else, for instance in the retroperitoneal tissue in the abdominal cavity, as well as
amputation of the penis and the creation of an artificial vagina. Some do all three, some
one or two of these. The type of surgical treatment offered women usually consists of
amputation of the breasts, sometimes combined with oophorectomy, and amputation of the
uterus. As a rule, these operations are combined with treatment with heterologous sex
hormones. Operations of this kind are one of the most controversial issues in the subject
of transsexualism. Many believe that one should not give in to the demands of the patients
for operation, because this alleviates the condition only for a time, and because it is
never possible to change a person's sex completely (Delay et al., 1956, Israel
& Geissmann, 1960).
So far, not many authors have been able to look on the problem quite impartially. Besides
medical and psychologic problems, transvestism/ transsexualism involves ethical, legal and
sometimes financial problems. Not only do individual physicians vary in their attitude to
surgical intervention (Green et al., 1966), so do also the different communities in
which the patients live, and the laws by which they must abide. Hence the great difference
in opinion on treatment.
One serious objection to surgical treatment is that, if the subject: change their mind
about their sexual role afterwards, nothing can be done to put them right again
anatomically. This is not purely an academic question-cases of this kind have been
reported (Bättig, 1952; de Savitsch, 1958; Hertz, Tillinger & Westman, 1961;
Hofer, 1961; Benjamin, 1964a). Again, some patients have great
difficulty in adjusting themselves to the change in their anatomy (Greenberg et al.,
1960, Bürger-Prinz et al., 1966). This is why reports of operation in these
cases often cause a storm of protest from colleagues (Boss, 1950; Ostow, 1953; Gutheil,
1954; Bremer, 1961).
Hamburger et al. (1953) after analyzing a case of male transsexualism, drew up the
following plan for the male cases in which surgical treatment was conceivable: (a)
permission for the patient to wear women's clothes, (b) legal recognition and registration
as a woman, (c) administration of estrogens, (d) castration, (e) demasculinization, and
(f), creation of an artificial vagina.
Benjamin (1966a) seems to have had the most experience of surgical treatment. lie
laid down a number of criteria which must be fulfilled for an operation to be successful,
and reported the results of operating on 51 men between 20 and 58 (castration
or placing the testes in the abdominal cavity, peotomy, and creation of an artificial
vagina), the period of observation varying between 3 months to 13 years,
with an average of 5 to 6 years. Nearly all the men lived and worked as
women; 12 had married but several had afterwards divorced. Taking into consideration the
whole life situation of these patients, and their mental and physical health, judging by a
follow-up examination and the reports of relatives, 44 out of the 51 had
benefited from the operation, in 5 cases the results were doubtful, in I case
unsatisfactory and in I case the outcome was unknown. He also reported the results of
operation in 9 female cases: good in 7 cases and doubtful in 1, and in I case unknown. Six
had married.
Pauly (1965) analyzed the results of operation in 48 male cases of transsexualism from the
literature: 42 of castration, 30 of amputation of the penis, and 20 of the creation of an
artificial vagina. In 20 of these 48, the man definitely benefited from the operation, I I
were apparently not benefited, and wanted more surgery, and in 6 cases the operation was
of no help at all. In I I cases no information on the outcome was given. Pauly (1966)
later reviewed the postoperative results of 99 male transsexuals who obtained sex
reassignment surgery: in 64 per cent the result was satisfactory, in so far as there was
an improvement is social and emotional adjustment; in 7 per cent the result was
unsatisfactory.
Positive results have been reported by many other authors (e.g., Abraham, 1931; Binder,
1933; Boss, 1950; Glaus, 1952; 1963, Hamburger et al., 1953; Fogh-Andersen, 1956; Bowman
& Engle, 1957; De Savitsch, 1958; Hertz et al., 1961; Anchersen, 1965). The authors
who approve of surgical measures for some cases point to the risk of the patients
mutilating themselves or committing suicide if they do not get help (e.g., Abraham, 1931;
Krause, 1964).
The reports on the results of operation are naturally colored by subjective opinion, and
no doubt more of the successful cases are reported than the unsuccessful. Likewise, many
authors give no definite criteria for what they consider to be physical, social or sexual
improvement.
Attempts to make an objective and all round evaluation of the questions in this connection
have been made by Dukor (1951), Anchersen (1956, 1961, 1965), Benjamin (1964a, b; 1966a),
Pauly (1965, 1966) and Stoller (1966).
Psychopharniaceutics and electroconvulsive therapy. When transvestism is associated with
an anxiety state, unrest or depression, the patients have been given the conventional
psychiatric methods of treatment for these conditions, such as insulin, electroconvulsive
treatment and different drugs (Lukianowicz, 1959a; Eyres, 1960; Pennington, 1960; Buki,
1964; Geert-Jorgensen, 1964; Johnsen, 1964).
Prognosis
As already mentioned, while transvestites are contented if they are allowed to dress in
the clothes of the opposite sex, transsexuals seldom remain satisfied with measures
undertaken on their behalf, but only keep on demanding more (e.g., Lukianowicz, 1959a).
The outlook seems to depend as a rule on the age of onset (e.g., Birker & Klages,
1961)-the earlier the onset the worse the outlook. Green & Money (1961) and Green
(1966) pointed out that one should not wait to see what happens when one sees an
incongruent gender role in early years, because this only gives it time to become fixed.
The importance of prophylaxis has been pointed out (e.g., Haberlandt, 1950; Green &
Money, 1961; Stoller, 1966) and Green & Money (1961) drew up a plan of treatment for
children showing an ambivalent sex role. Other authors have also said that one can do more
to help when the patients are young than when they grow up (Dorey, 1956; Alby, 1959;
Goldrach, 1963 and Roth & Ball, 1964).
As observed by Nathan (1965) and Stoller (1966) women seem to have less severe forms of
the deviation than men.
A picture of the general outlook in transvestism and transsexualism would not be complete
without taking into account the risk of suicide and self-mutilation. Pauly (1965) found
that 35 out of the 100 transsexuals he collected from the literature had threatened to
commit suicide, 17 had attempted to do so, and 18 had tried or succeeded in amputating
offending parts of their body. |
